CurrentBlue Cross Blue Shield - TexasPolicy N/A

Prior Authorization & Referral Requirements List — HealthSelect of Texas Out-of-State Plan participants

Defines prior authorization and referral requirements for HealthSelect of Texas Consumer Directed HealthSelectSM Out-of-State Plan participants using the Blue Card PPO network, including when Medical Management review is required and rules for in-network and out-of-network services.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization & Referral Requirements List — HealthSelect of Texas Out-of-State Plan participants

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2020

Next Review DateN/A

Key ActionObtain Medical Management prior authorization for services that require prior authorization; contact eviCore for certain services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Requires Medical Management ReviewPrior authorization general requirement

Out-of-Network review requiredOut-of-network services policy

eviCore usedExternal vendor for prior auth

No PCP requiredPrimary care/follow-up requirement

Specialty drugs & select DME

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Prior Authorization Criteria and Exceptions

Prior authorization criteria and exceptions

Services and situations that require prior authorization, referral guidance, and exceptions.

Prior authorization requires Medical Management review.

Out-of-network services

Out-of-network services require Medical Management Review for services that require prior authorization; emergency services are excepted.
Request review through Availity Authorization & Referrals/Medical Management.

Services commonly requiring prior authorization

Outpatient private duty nursing
Home infusion therapy (non-network not covered)
Home health (exception: home dialysis does not require prior authorization)
Select durable medical equipment (DME) with cost greater than $1,000 (including but not limited to prosthetic devices)
Non-emergent air and ground ambulance
Congenital heart disease services
Reconstructive procedures (including but not limited to breast reduction surgery)
Transplant services
Outpatient surgery — facility setting (including diagnostic catheterization; electrophysiology implant and sleep apnea procedures)
Orthognathic surgery
Specialty drugs (see qualifying drug list)
Outpatient mental health services and certain behavioral health services (including Intensive Outpatient Program for MH and SUD; rTMS; ECT; Applied Behavioral Analysis)
Prior authorization for first visits: First visits for physical therapy, speech therapy, and occupational therapy do not require prior authorization; all subsequent visits require an approved prior authorization with a treatment plan.

Vendor-managed prior authorization

Certain services require prior authorization through eviCore; consult eviCore (evicore.com or 855-252-1177) for specific codes and requirements.

Referral / PCP rules

Participants using the Blue Card PPO network do not have to designate a PCP and in-network referrals are not required.
No referrals or prior authorizations required if Medicare is primary.

Not covered / plan exceptions

Bariatric surgery is not covered under the HealthSelect Out-of-State Plan.

How to request review

Submit prior authorization and referral requests through Availity Authorization & Referrals/Medical Management.

Notes

Emergency services are excepted from out-of-network Medical Management Review requirements.

Title: Prior authorization criteria and exceptions

Code Lists and DME Thresholds

eviCore code listmixed

Specific procedure and billing codes are maintained by eviCore; consult eviCore site for applicable codes.

DME cost threshold

ThresholdSelect durable medical equipment (DME) greater than $1,000 requires prior authorization (includes but is not limited to prosthetic devices)

ScopeApplies to select DME items identified in the Prior Authorization & Referral Requirements List

Exception guidanceHome dialysis is an exception to prior authorization requirements for home health (no prior authorization required)

Action to obtain authorizationPrior authorization is obtained through Availity Authorization & Referrals/Medical Management per the policy

Prior Authorization Process and Provider Responsibilities

Prior Authorization

Submit prior authorization for review by Medical Management; out-of-network requires review

Prior authorization requests must be submitted for services that require authorization and will undergo Medical Management review. Out-of-network services that require prior authorization also require Medical Management review; emergency services are excepted. If Medicare is primary, no referrals or prior authorizations are required.

Submit prior authorization through Availity Authorization & Referrals/Medical Management for services on the prior authorization list.
Out-of-network services requiring prior authorization must have Medical Management review or benefits may be reduced or denied.
Emergency services are exempt from the out-of-network prior authorization requirement.

Prior Authorization

Use eviCore for designated prior authorizations

Certain prior authorizations must be obtained through eviCore. Contact eviCore at evicore.com or toll-free 855-252-1177 and consult the eviCore website for the specific procedure and billing codes that apply.

Key Terms and Network Rules

Medical Management Review

TermMedical Management Review

DefinitionPrior authorization requires Medical Management Review as stated in the Prior Authorization & Referral Requirements List

Related processPrior authorizations (including those routed through Availity Authorization & Referrals) are subject to Medical Management Review

In-network referral/PCP rule

RuleBlue Card PPO network participants do not have to designate a Primary Care Physician (PCP)

Referral requirementIn‑network referrals are not required for participants using the Blue Card PPO network