CurrentBlue Cross Blue Shield - TexasPolicy N/A

Prior Authorization rules - Medicare Advantage Medical / Surgical/Behavioral Health

Defines prior authorization and notification requirements for Blue Cross and Blue Shield of Texas Medicare Advantage medical, surgical and behavioral health services, and describes which services require prior authorization and how to request it (including eviCore). Applies to providers serving BCBSTX Medicare Advantage members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization rules - Medicare Advantage Medical / Surgical/Behavioral Health

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionUse the eviCore Healthcare Web Portal to initiate prior authorization cases, check status, review guidelines and view authorizations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

prior auth requiredinpatient elective admissions

1 business dayemergency admission notification

eviCorethird‑party vendor

OON prior authnetwork participation

retrospective review

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.

Coverage and Prior Authorization Criteria

Coverage and prior authorization criteria

Service-level prior authorization expectations and examples (not exhaustive); consult the comprehensive prior authorization grid and the member benefit booklet for definitive requirements.

Prior authorization requirements vary by procedure code and member benefit; always consult the member benefit booklet and the comprehensive prior authorization grid for definitive requirements.

A prior authorization is not a guarantee of payment; final payment is determined at claim processing and is subject to member eligibility and the member's certificate of coverage.

Medical necessity must be met for all services; services are subject to retrospective review and potential recoupment.

Inpatient and emergency admissions

Planned (elective) inpatient hospital admissions require prior authorization.
All inpatient stays are subject to review; inpatient stays with services managed by eviCore will be reviewed through eviCore.
In cases of emergency (unplanned) admissions, notification to BCBSTX is required within one business day of admission.

Common service categories (examples)

Bariatric surgery and certain surgical procedures: prior authorization required; refer to the procedure code list/prior authorization grid.
Transplants and pre-transplant evaluations: prior authorization required.
Chemotherapy and radiation therapy: prior authorization required.
Skilled nursing facility admissions and partial hospitalization: prior authorization required.
Special rehabilitation services (physical therapy, occupational therapy, speech therapy, cardiac and pulmonary rehabilitation): prior authorization required; consult the procedure code list.
Diagnostic imaging (PET, MRA, MRI, CT) and many laboratory/imaging tests: refer to the procedure code list for prior authorization requirements.

Services that commonly do NOT require prior authorization (examples)

Routine physicals: typically do not require prior authorization; verify via member benefits and code grid.
Office visits to PCPs or specialists (certain codes): may not require prior authorization per member contract — confirm via the procedure code list and member benefit booklet.
Elective procedures and services not listed on the prior authorization grid may still require review depending on member plan; always confirm.

Out-of-network providers must seek prior authorization for all services except emergency services, emergency ambulance services, stabilization services, and Indian Health Services; verify exceptions via the procedure code list and member contract.

Use of third‑party UM vendor: eviCore is used by BCBSTX to manage utilization review for select services; providers should follow eviCore processes where applicable (portal, phone) to request review and obtain authorizations.

How to request prior authorization (operations): Initiate prior authorization requests and check status using the eviCore Healthcare Web Portal for services managed by eviCore; call eviCore or BCBSTX prior authorization phone numbers for Medicare Advantage as needed.

Procedure Codes and Prior Authorization Grid

Prior authorization code gridmixed

Comprehensive prior authorization grid lists procedure codes that require review; consult the grid for specific code requirements.

Refer to member contract / procedure code list

GuidanceCoverage and prior authorization vary by procedure code and member benefit; consult the member benefit booklet and the comprehensive prior authorization grid for definitive code-level requirements.

Where to checkView the comprehensive prior authorization grid on the BCBSTX Clinical Resources > Prior Authorizations and Predeterminations page; the grid is searchable (use Ctrl+F).

Codes on listThe presence of codes on the limitations list does not necessarily indicate coverage under the member benefits contract—confirm via the member certificate of coverage.

ExamplesMany services (e.g., bariatric surgery, chemotherapy, PET/MRI/CT, DME, transplants, skilled nursing facility care) require prior authorization—refer to the grid for specific codes.

How to Request Authorization and Admission Notifications

Prior Authorization

How to request prior authorization

Use the eviCore Healthcare Web Portal to initiate prior authorization cases, check case status, review clinical guidelines, and view authorizations and eligibility. Phone contact options are available for certain services (for example, eviCore toll-free 1-855-252-1117 for Sleep services and Medicare Advantage medical/surgical/behavioral health via BCBSTX toll-free 1-877-774-8592). Portal use is the most efficient method for molecular genetics, musculoskeletal (spine/joint/pain), sleep, and specialty drug reviews.

eviCore Healthcare Web Portal: initiate cases, check status, review guidelines, view authorizations/eligibility
Phone: Sleep services — eviCore toll-free 1-855-252-1117 (hours vary by service)
Medicare Advantage Medical/Surgical/Behavioral Health: BCBSTX toll-free 1-877-774-8592, 8 a.m. to 8 p.m. CST Mon–Fri

Prior Authorization

Admission authorization and notification

Prior authorization is required for all planned (elective) inpatient hospital care including surgical, non-surgical, behavioral health, and substance abuse admissions. Elective admissions must have prior authorization before the admission occurs. Notification is required for all unplanned inpatient hospital care — notification must be made within one business day of admission. Admissions to skilled nursing facilities, long term acute care hospitals, rehabilitation facilities, and residential treatment programs also require authorization or notification as applicable.

Policy Definitions and Notes

Medical necessity

Medical necessity requirementMedical necessity must be met for all services regardless of prior authorization status.

Retrospective reviewAll services are subject to retrospective review and recoupment in accordance with State and Federal rules and regulations.

Payment not guaranteedPrior authorization is not a guarantee of payment; benefits are determined at claim processing per the member's certificate of coverage.

eviCore

Role of eviCoreeviCore® is an independent utilization review vendor that conducts utilization review for select health care services on behalf of Blue Cross and Blue Shield of Texas.

How to use eviCoreUse the eviCore Healthcare Web Portal to initiate cases, check status, review guidelines and view authorizations for covered service categories; phone support is available for select services.