CurrentBlue Cross Blue Shield - TexasPolicy N/A

Prior Authorization & Referral Requirements for Out-of-State Plan Participants

Governs prior authorization and referral requirements for HealthSelect of Texas Consumer Directed HealthSelect out-of-state plan participants, including in-network and out-of-network rules and how to request authorizations. Affects plan participants and providers managing authorizations and referrals.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization & Referral Requirements for Out-of-State Plan Participants

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2022

Next Review DateN/A

Key ActionUse Availity Authorization & Referrals to prior authorize services managed by BCBSTX Medical Management and set up referrals when necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2022-09-01policy effective date

1-800-859-5299AIM contact

Availityprimary portal

ExemptMedicare primary

Prior Authorization & Referral Coverage Criteria

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Prior Authorization and Referral Criteria

Services listed require prior authorization (in-network and out-of-network as specified) and Medical Management review unless otherwise indicated. Emergency services are exempt. If Medicare is primary, no referrals or prior authorizations are required.

ALL of the following

Admissions including transfers to: hospital, rehabilitation, long-term acute care (LTAC), sub-acute facilities, inpatient hospice, skilled nursing (facility-based)
Congenital heart disease services
Reconstructive procedures (including but not limited to breast reduction surgery)
Transplant services
Orthognathic surgery
Inpatient mental health services: inpatient, residential, and partial stays (neurobiological and substance use disorder facility stays)

ALL of the following

Outpatient surgery (facility-based), including diagnostic catheterization, electrophysiology implant, and sleep apnea procedures
Advanced radiology imaging and radiation oncology services for outpatient and office settings
Specialty drugs and specialty medical oncology drugs (some oncology drugs require AIM review)
Outpatient mental health services including Intensive Outpatient Program (IOP), rTMS, ECT, and Applied Behavioral Analysis (ABA) for autism spectrum
Molecular and genomic testing
Bariatric surgery (not covered under HealthSelect Out-of-State plan)

ALL of the following

First visits for physical therapy, occupational therapy, and speech therapy do not require prior authorization; all subsequent visits require an approved prior authorization that includes a treatment plan
Emergency services are exempt from prior authorization requirements
When Medicare is the primary payer, no referrals or prior authorizations are required

ALL of the following

In-network providers: no referral required for services provided by network providers; prior authorization requirements still apply where listed
Out-of-network providers: out-of-network services that are listed require Medical Management review and prior authorization; benefits may be reduced or denied if authorization is not obtained (emergency services excepted)

Service Categories, Therapy Visit Auth, and Coding Guidance

Service categoriesmixed

List references multiple service types (advanced imaging, radiation oncology, outpatient surgery, specialty drugs) but does not list specific CPT/HCPCS/ICD codes.

Therapy visit authorization — PT/OT/Speech

Authorization requirementFirst visits for physical therapy, speech therapy, and occupational therapy do NOT require prior authorization; all subsequent visits require an approved prior authorization that includes a treatment plan.

ScopeApplies to outpatient PT/OT/speech services as listed in the Prior Authorization & Referral Requirements effective September 1, 2022.

How authorization is obtainedPrior authorization for subsequent visits must be requested via Availity Authorization & Referrals (see Medical Management review requirement).

Consequences of no authorizationSubsequent visits without an approved prior authorization and treatment plan may not meet medical management requirements and could result in reduced or denied benefits per the policy.

How Providers Request Authorizations and Required Actions

Prior Authorization

How to Request Prior Authorization

Use Availity® Authorization & Referrals to request prior authorization for services managed by BCBSTX Medical Management and to set up referrals when required. Log into the Availity portal and select Authorization & Referrals. For services managed by AIM Specialty Health (AIM), use the AIM provider portal or call 1-800-859-5299. If Medicare is primary, referrals and prior authorizations are not required. Emergency services are exempt from prior authorization requirements. Failure to obtain required prior authorization for out-of-network services may result in reduced benefits or denied claims.

Availity Authorization & Referrals portal — primary route for BCBSTX-managed prior authorizations and referrals
AIM Specialty Health portal or 1-800-859-5299 for AIM-managed reviews
Medicare-primary members: no referrals or prior authorizations required
Emergency services: prior authorization not required

Prior Authorization

Services Requiring Prior Authorization

The following services require prior authorization (request via Availity Authorization & Referrals unless otherwise indicated). Where noted, Medical Management review is required. This list includes, but is not limited to:

Inpatient admissions and transfers (hospital, rehab, long-term acute care, sub-acute, inpatient hospice, inpatient rehabilitation) — Medical Management review required
Skilled nursing facility (facility-based) admissions
Congenital heart disease services
Reconstructive procedures (e.g., breast reduction)
Transplant services
Orthognathic surgery
Obstetrical care — maternity notification/prior authorization as indicated
Inpatient mental health services (inpatient, residential, partial stays) and related behavioral health admissions — prior authorization required
Outpatient surgery in facility settings (including diagnostic catheterization, electrophysiology, implant procedures, sleep apnea procedures)
Specialty drugs and specialty medical oncology drugs — prior authorization; contact AIM for oncology drug reviews when indicated
Radiation oncology for outpatient and office services
Advanced radiology/imaging (e.g., high-tech imaging) — prior authorization required
Outpatient mental health services (including IOP for MH and SUD, rTMS, ECT, and Applied Behavioral Analysis for autism) — prior authorization required
Outpatient home infusion therapy (coverage varies; non-network not covered) and private duty nursing — prior authorization required
Home health services (except home dialysis) — prior authorization may be required
Non-emergent air and ground ambulance services — prior authorization required
Molecular and genomic testing — prior authorization required

Note

Referral Requirements

Referral requirements: network providers generally do not need to submit referrals for services; however, referrals or prior authorization may be required for out-of-network services and certain listed services. For out-of-network services that require prior authorization, contact Medical Management via Availity Authorization & Referrals. If Medicare is primary, no referrals or prior authorizations are required.

In-network: no referral required for network providers for the services listed
Out-of-network: prior authorization and Medical Management review may be required for certain services; benefits may be reduced or denied if prior authorization is not obtained
Medicare-primary: referrals and prior authorizations are not required
Use Availity Authorization & Referrals to set up referrals when necessary

Definitions and Vendor Partners

Availity (portal)

DefinitionAvaility is a separate company that operates a health information network to provide electronic information exchange services to medical professionals and administrative services to BCBSTX.

Primary usePrimary portal for submitting prior authorizations and referrals for services managed by BCBSTX Medical Management (Availity Authorization & Referrals).

Relationship to BCBSTXProvides administrative and electronic information exchange services but is a third-party vendor; BCBSTX makes no endorsement or warranty of Availity products or services.

AIM Specialty Health (AIM)

DefinitionAIM Specialty Health (AIM) is an independent company contracted by BCBSTX to provide utilization management services for members.

Contact/roleAIM conducts utilization review for certain services per the Prior Authorization & Referral Requirements and can be contacted via its provider portal or phone as specified in BCBSTX communications.

Relationship to prior authorization processSome oncology drugs and other services may require AIM review as part of the Medical Management prior authorization process described in the policy.