Prior Authorization Services for Fully Insured & Certain Administrative Services Groups
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Texas policy alerts
Know when Blue Cross Blue Shield - Texas releases new policies or updates existing guidance.
Monitor payer policy activity
Defines prior authorization requirements and vendor routing for fully insured and certain administrative services groups of Blue Cross Blue Shield of Texas, including which services require authorization and where providers should verify requirements.
No material clinical or coverage changes in this revision.
Services and Coverage Criteria
Services requiring prior authorization or clinical review
Services that require prior authorization or clinical review for fully insured and certain administrative services groups include (but are not limited to) the following categories and examples:
Outpatient medical/surgical services (vendor managed)
- Advanced imaging (radiology, cardiology) — routed to Carelon Medical Benefits Management.
- Molecular genetic laboratory testing — routed to Carelon Medical Benefits Management.
- Radiation therapy / radiation oncology — routed to Carelon Medical Benefits Management.
- Musculoskeletal services including joint and spine surgery, musculoskeletal pain — routed to Carelon Medical Benefits Management.
- Sleep services — routed to Carelon Medical Benefits Management.
- Cardiology lipid apheresis.
Select outpatient services (BCBSTX managed)
- Ear, nose and throat services.
- Gastroenterology services.
- Outpatient surgery (examples: breast procedures, deactivation of headache triggers, jaw surgery).
- Neurology services.
- Pain management services.
- Sleep studies.
- Wound care.
Mental health and substance use disorder outpatient services
- Applied Behavioral Analysis (ABA).
- Electroconvulsive therapy (ECT).
- Intensive outpatient treatment (IOP).
- Partial hospitalization (PHP).
- Repetitive transcranial magnetic stimulation (rTMS).
- Psychological testing / neuropsychological testing.
Home-based and related services
- Home private duty nursing (PDN).
- Home infusion therapy (HIT) and infusion site-of-care reviews for therapy and place of infusion.
- Physical, occupational and speech therapy provided in the home (PT/OT/ST).
- Home hemodialysis.
- Home hospice.
Transportation, transplant and out-of-network services
- Medical transportation (managed through Alacura Medical Transportation Management or BCBSTX as indicated).
- Non-emergency fixed-wing air ambulance.
- Transplant services including transplant evaluations and transplants.
- Outpatient elective surgery received in an out-of-network hospital or ambulatory surgical center.
- Dialysis obtained from an out-of-network provider.
Oncology and provider-administered drug therapies
- Medical oncology and supportive care — medical necessity review required for oncology drugs supported by an oncology diagnosis (routed to Carelon where indicated).
- Provider-administered drug therapies — medical necessity review required; some medications additionally require prior authorization per the drug list/step therapy programs or pharmacy benefits rules.
Other services
- Select procedures and services not explicitly listed above may require prior authorization. Providers should refer to downloadable procedure code lists or the provider portal for comprehensive lists (procedure codes not included in this document).
- For elective inpatient services that do not require prior authorization, follow the Recommended Clinical Review Services List for Fully Insured & Certain Administrative Services Only Groups; for unplanned inpatient admissions, seek clinical review within 48 hours to avoid post-service medical necessity reviews.
Codes, Coding Notes, and Drug Evidence Thresholds
| Document notes that procedure codes for prior authorization are not available in this document and refers providers to downloadable lists or provider portal. |
Provider Verification, Routing, and Prior Authorization Actions
Provider Verification and Inpatient Review Timing
Providers must check eligibility and benefits and verify prior authorization requirements through Availity Essentials before delivering services. For all unplanned inpatient admissions (surgical, non-surgical, mental health and/or substance use disorder), seek Clinical Review within 48 hours of admission to prevent post-service medical necessity reviews that may result in adverse determinations.
- Check eligibility/benefits and prior authorization requirements via Availity Essentials.
- For unplanned inpatient admissions, request Clinical Review within 48 hours.
Service Routing to External Vendors
Certain service lines are routed to external vendors for prior authorization and medical necessity review. Providers should confirm routing and requirements via Availity Essentials and the Utilization Management resources on the BCBSTX provider website.
- Advanced Imaging Radiology, Cardiology — Carelon Medical Benefits Management
- Molecular Genetic Lab Testing — Carelon
- Radiation Therapy / Radiation Oncology — Carelon
- Musculoskeletal (Joint; Spine Surgery; Musculoskeletal Pain) — Carelon
- Sleep — Carelon
- Cardiology Lipid Apheresis — routing as indicated
- Select outpatient services (ENT, Gastroenterology, specified outpatient surgeries, Neurology, Pain Management, Sleep Studies, Wound Care) — BCBSTX
Drug Therapy Prior Authorization and Medical Necessity Reviews
Provider-administered drug therapies (including oncology and supportive care drugs) and certain infusion-site-of-care determinations require prior authorization and a medical necessity review. Medical necessity reviews for oncology drugs are routed through Carelon when required. Drug therapy reviews use BCBSTX Medical Policies and authoritative references (FDA labeling, NCCN, DrugDex, MCG, professional society guidelines, CMS) to evaluate dose, frequency, duration, and indication. Some medications also require prior authorization under pharmacy benefits or step therapy—check the drug list guide and the Prior Authorization/Step Therapy Program information to determine specific requirements.
- Provider-administered oncology and supportive care drugs — medical necessity review through Carelon when oncology diagnosis supports review
- Infusion Site of Care — medical necessity review required for therapy and place of infusion
- Provider-administered drug therapies — follow BCBSTX Medical Policies and referenced authoritative sources (NCCN, DrugDex, MCG, FDA labeling)
- Check the drug list guide and Prior Authorization/Step Therapy Program for pharmacy-benefit prior authorization requirements
Home and Out-of-Network Services Requiring Prior Authorization
Home-based services and most out-of-network/out-of-plan services require prior authorization. Examples include private duty nursing (PDN), home infusion therapy (HIT), home hemodialysis, home hospice, and other home health services. Non-emergency medical transportation is managed through Alacura Medical Transportation Management for applicable accounts. Outpatient elective surgery, dialysis, transplants, and other services obtained from out-of-network providers also require prior authorization or out-of-network/ out-of-plan authorization. Providers should verify whether prior authorization is required and follow the documented routing (BCBSTX or contracted vendors) for these services.
- Home private duty nursing (PDN) — prior authorization required
- Home Infusion Therapy (HIT) — prior authorization required; infusion site-of-care medical necessity review may apply
- Home Hemodialysis — prior authorization required
- Home Hospice — prior authorization required
- Medical Transportation (non-emergency) — managed by Alacura Medical Transportation Management for applicable accounts
- Out-of-Network/Out-of-Plan services (e.g., outpatient elective surgery in out-of-network facility, dialysis from out-of-network provider, transplants and transplant evaluations) — prior authorization/out-of-plan authorization required
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.