Prior Authorization rules Medicare Advantage Medical Surgical/Behavioral Health
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Governs prior authorization, notification, and medical necessity requirements for Blue Cross and Blue Shield of Texas Medicare Advantage members for medical, surgical, and behavioral health services; applies to in-network and out-of-network providers as specified.
No material clinical or coverage changes in this revision.
Coverage and Prior Authorization Criteria
Coverage criteria summary
Summary of prior authorization expectations and notable service-level stances; final benefit determination depends on the member's contract and claims adjudication.
Inpatient admissions
- Elective (planned) inpatient hospital care requires prior authorization.
- Unplanned (emergency or unplanned) inpatient admissions require notification within one business day of admission.
Routine and office services
- Office visits and routine physicals generally do not require prior authorization as noted.
- Second opinions (in-network) generally do not require prior authorization.
Procedure Codes and Vendor Effective Dates
| Refer to the payer's procedure code list for specific services and CPT/HCPCS codes that require prior authorization. |
What Providers Must Do
How to request prior authorization
Use the eviCore Healthcare Web Portal to initiate prior authorization cases, check case status, review guidelines, and view authorizations and eligibility; for specific service lines follow the call instructions for eviCore or use the BCBS Texas prior authorization line for Medicare Advantage as directed in the document.
- eviCore Web Portal is the most efficient way to initiate a case, check status, review guidelines, view authorizations and eligibility.
- For Medicare Advantage prior authorization questions, the BCBSTX prior authorization toll-free line is available as directed.
Inpatient admissions authorization and notification
Prior authorization is required for all planned (elective) inpatient hospital care; unplanned (emergency/unplanned) inpatient admissions must be notified to the payer within one business day of admission.
- Elective admissions must have authorization before the admission occurs.
- Notification for unplanned inpatient hospital care must be made within one business day of admission.
Network participation and exceptions
Out-of-network providers must obtain prior authorization for all services, except for emergency services, emergency ambulance services, stabilization, and services provided by Indian Health Services.
- Prior authorization requirement applies to out-of-network providers unless the service is an exception listed in the policy.
Medical necessity requirement
All services must meet medical necessity regardless of prior authorization status; services are subject to retrospective review and potential recoupment in accordance with state and federal rules and regulations.
- Authorization does not guarantee payment — benefits are determined at claim adjudication based on eligibility and the certificate of coverage.
- Retrospective review and recoupment follow State and Federal rules and regulations.
Definitions and Notification Terms
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