CurrentBlue Cross Blue Shield - TexasPolicy N/A

Prior Authorization requirements - Medicare Advantage (Medical/Surgical/Behavioral Health)

Defines prior authorization and notification requirements, network participation, medical necessity, and lists services requiring prior authorization for Blue Cross and Blue Shield of Texas Medicare Advantage plans. Affects in-network and out-of-network providers serving BCBSTX Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization requirements - Medicare Advantage (Medical/Surgical/Behavioral Health)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date07/01/2023

Next Review DateN/A

Key ActionProviders must use the eviCore Healthcare Web Portal (or listed vendor phone numbers) to request prior authorization for specified services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

eviCoreeviCore routing

1-877-774-8592BCBSTX prior auth phone

1 business dayEmergency notification

Auth requiredPlanned inpatient care

Refer to gridCode-level auth

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services Requiring Prior Authorization

Service-specific prior authorization stance

Examples of services and whether prior authorization is required or to refer to the procedure code list:

Bariatric surgery — Prior Authorization = Yes

Blepharoplasty — Prior Authorization = Yes

Botox injections — Prior Authorization = Yes

Chemotherapy and radiation therapy — Prior Authorization = Yes

Dental care — Prior Authorization = Yes

DME, medical supplies, orthotics and prosthesis — Refer to the procedure code list for benefit prior authorization requirements

Ground ambulance — Prior Authorization = No; Air (fixed wing) — Prior Authorization = Yes (fixed wing medical transportation)

Home health care and intravenous services — Refer to the procedure code list for benefit prior authorization requirements

Hospital services (inpatient, outpatient) — Reviewed through eviCore; inpatient stays with services managed by eviCore will be reviewed through eviCore

Implantable devices — Prior Authorization = Yes

Laboratory, X-ray, EKGs, medical imaging services, and other diagnostic tests — Refer to the procedure code list for benefit prior authorization requirements

Long Term Acute Care (LTAC, TX only) — Prior Authorization = Yes; reviewed through eviCore

Minor surgeries — Refer to the procedure code list for benefit prior authorization requirements

Network exceptions including out-of-plan or out-of-network (due to network adequacy) — Refer to the procedure code list for benefit prior authorization requirements

Nutritional counseling services — Refer to the procedure code list for benefit prior authorization requirements

Nutritional products and special medical foods — Prior Authorization = Yes

Office visits to PCPs or specialists (including dieticians, nurse practitioners, and physician assistants) — Prior Authorization = No

Podiatry (foot and ankle) services — Refer to the procedure code list for benefit prior authorization requirements

PET, MRA, MRI, and CT scans — Refer to the procedure code list for benefit prior authorization requirements

Routine physicals — Prior Authorization = No

Second opinions (in network) — Prior Authorization = No

Skilled nursing facilities — Prior Authorization = Yes

Special rehabilitation services (physical therapy, occupational therapy, speech therapy, cardiac) — Prior Authorization = Yes; refer to the procedure code list for benefit prior authorization requirements

Surgery (including pre- and post-operative care: assistant surgeon, anesthesiologist, organ transplants) — Refer to the procedure code list for benefit prior authorization requirements; all transplants and pre-transplant evaluation require prior authorization

Intersex reassignment surgery (CPT 55970, 55980) — Prior Authorization = Yes

Partial hospitalization — Prior Authorization = Yes

Psychological/Neuropsychological testing — Prior Authorization = Yes upon notification by BCBSTX

Electroconvulsive therapy — Prior Authorization = Yes

Transcranial Magnetic Stimulation — Prior Authorization = Yes

Outpatient services — Refer to the procedure code list for benefit prior authorization requirements

Procedure Codes and Reference Grid

Covered CPT CodesCPTCovered

55970	Intersex Reassignment Surgery
55980	Intersex Reassignment Surgery

Refer-to-grid

PointerSee the comprehensive prior authorization grid / procedure code list for specific codes requiring prior authorization; the grid is searchable (use CTRL+F).

ScopeThe grid lists procedure-level prior authorization requirements for imaging, DME, home health, surgery, outpatient services, and many other services; presence on the list does not guarantee coverage — check member benefits.

Access noteFor inpatient stays and services managed by eviCore, review and authorization workflows are handled through eviCore as indicated in the grid entries.

How Providers Request Authorization & Notification Requirements

Prior Authorization

How to Request Prior Authorization — eviCore and BCBSTX Contact Points

Prior Authorization is required for many services. Initiate cases, check status, and view authorizations via the eviCore® Healthcare Web Portal for radiology, medical oncology, molecular genetics (portal OR phone where noted), and other specified services. For musculoskeletal (spine/joint/pain) services call eviCore toll-free at 1-855-252-1117 between 7 a.m. and 7 p.m. local time Monday through Friday. Radiation therapy, sleep services (TX only) and specialty drug prior authorization have specific hours of operation; refer to the BCBSTX prior authorization lists or the eviCore portal for the full list and details. Medicare Advantage medical/surgical/behavioral health prior authorization is handled through Blue Cross and Blue Shield of Texas at 1-877-774-8592 between 8 a.m. and 8 p.m. (CST) Monday–Friday (except holidays). Behavioral health for Blue Cross Medicare Advantage HMO requires prior authorization from Magellan Healthcare at 1-800-327-9251.

Use the eviCore® Healthcare Web Portal as the primary method to request prior authorization for radiology, medical oncology, molecular genetics, and other listed services.
Musculoskeletal (Spine/Joint/Pain): call eviCore 1-855-252-1117, 7 a.m.–7 p.m. local time, Mon–Fri.
Medicare Advantage Medical/Surgical/Behavioral Health prior auth: BCBSTX 1-877-774-8592, 8 a.m.–8 p.m. CST, Mon–Fri (except holidays).
Behavioral Health for Medicare Advantage HMO: Magellan Healthcare 1-800-327-9251.

Key Terms

eviCore

DefinitioneviCore Healthcare Web Portal — an online portal used to initiate cases, check status, review guidelines, and view authorizations and eligibility for select services (radiology, medical oncology, molecular genetics, etc.).

Scope of useeviCore is used for radiology, medical oncology, molecular genetics, many inpatient stays with eviCore-managed services, and select other services per the prior authorization rules.

Contact alternativesFor certain musculoskeletal services providers may call eviCore toll-free at 1-855-252-1117 during business hours as noted in the policy.

Prior Authorization Note

Payment disclaimerPrior authorization/pre-certification is not a guarantee of payment; benefits are determined when a claim is received and are based on member eligibility and the member's certificate of coverage.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization requirements - Medicare Advantage (Medical/Surgical/Behavioral Health)

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date07/01/2023

Next Review DateN/A

Key ActionProviders must use the eviCore Healthcare Web Portal (or listed vendor phone numbers) to request prior authorization for specified services.

SourceLink

On This Page

Prior Authorization

Network Participation / Out-of-Network Prior Auth

Out-of-network providers must obtain prior authorization for all services except for emergency services, emergency ambulance services, stabilization services, and services provided by Indian Health Services. This requirement applies even when network exceptions are granted for managed programs; confirm any network-exception details with BCBSTX.

Out-of-network providers: prior authorization required for all services unless the service is an emergency, emergency ambulance, stabilization, or provided by Indian Health Services.
Network exceptions (out-of-plan or out-of-network due to network adequacy) are included in prior authorization processes — verify via BCBSTX prior authorization lists.

Prior Authorization

Admission Notification Requirements

Notification is required for emergency admissions and for certain unplanned inpatient care. For emergencies, the facility must notify the health plan within one business day of the admission. Planned (elective) inpatient hospital admissions require prior authorization before the admission occurs.

Emergency admissions: notify BCBSTX within one business day of admission.
Planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse): prior authorization required before the admission.
Unplanned inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse): notification required within one business day of admission.

Denial Risk

Medical Necessity and Retrospective Review

All services must meet medical necessity criteria regardless of prior authorization status. Services are subject to retrospective review and potential recoupment in accordance with applicable state and federal rules and regulations.

Medical necessity must be met for all services.
All services are subject to retrospective review and recoupment per State and Federal rules and regulations.

Authorization only indicates pre-certification; final coverage/payment decisions occur at claim adjudication based on contract terms applicable on the date services were rendered.

Implication for providersEven if a service appears on the grid and is authorized, verify member-specific benefit limits and eligibility before assuming payment responsibility.