Prior Authorization Requirements for Medicare Advantage Medical, Surgical and Behavioral Health Services
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This document governs prior authorization, notification, and medical necessity requirements for Medicare Advantage members and providers contracting with Blue Cross and Blue Shield of Texas; it describes which services require prior authorization, network/notification rules, and how to request authorizations.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Prior authorization and notification requirements for inpatient services
Covered when ALL of the following are met:
Chunk 4
Chunk 4
Chunk 3
Out-of-network providers are required to obtain prior authorization for all services except in specific circumstances. The documented exceptions are emergency services, emergency ambulance services, care necessary for stabilization, and services provided by Indian Health Services. For planned (elective) care, out-of-network providers must follow standard prior authorization processes; for emergency or stabilization situations, the prior authorization requirement does not apply but applicable notification rules and member protection provisions remain in effect.
All services must meet medical necessity criteria regardless of whether prior authorization was obtained. If a service is determined to be not medically necessary upon retrospective review, the determination may result in denial of coverage and potential recoupment in accordance with applicable State and Federal rules and regulations.
Procedure and Code Lists
| see procedure code list | Comprehensive list of codes that require prior authorization (portal/grid) |
Provider Responsibilities and Prior Authorization Workflow
Prior Authorization Required
Prior authorization is required for the categories listed below and for specific procedure codes available in the BCBS Texas prior authorization grid. Use the eviCore Healthcare Web Portal as the preferred method to initiate authorization requests, check status, review guidelines, and view authorizations and eligibility. Failure to obtain required prior authorization may result in retrospective review, denial of payment, and recoupment in accordance with State and Federal rules and regulations.
- Refer to the BCBS Texas prior authorization procedure code grid for the full, detailed list of codes and service-specific requirements.
- Network exceptions (out-of-plan or out-of-network due to network adequacy) are included; check the procedure code grid and member contract for applicability.
- Medical necessity must be met for all services regardless of prior authorization status; all services are subject to retrospective review and recoupment.
Provider Obligations
Providers must initiate prior authorization requests and maintain documentation supporting medical necessity. Confirm member benefits and eligibility before providing services. Keep copies of submitted requests and any authorizations received. If services are provided without required authorization, the claim may be denied and subject to recoupment.
- Verify member-specific coverage in the member benefit booklet or via BCBS Texas clinical resources.
- Maintain and produce clinical documentation upon request to support medical necessity determinations.
- Follow any eviCore clinical guideline instructions communicated during the review process.
How to Initiate Prior Authorization
Use the eviCore Healthcare Web Portal to submit and manage authorization cases. If portal access is not available, BCBS Texas prior authorization phone lines may be used as an alternative. Portal use is the most efficient way to initiate cases, check status, review guidelines, and view authorizations and eligibility.
- eviCore Healthcare Web Portal — preferred: submit new cases, upload documentation, check case status, and view authorization decisions.
- BCBSTX Prior Authorization Phone (TX only): 1-877-774-8592, Monday–Friday 8:00 a.m. to 8:00 p.m. CST (except holidays).
- eviCore phone support (for categories managed by eviCore): Monday–Friday 6:00 a.m. to 6:00 p.m. CST; limited weekend/holiday hours may apply (e.g., 9:00 a.m. to 12:00 p.m. CST on some weekends/holidays).
Denial Risk and Recoupment
Services that do not meet medical necessity criteria are subject to retrospective review. Denials following retrospective review may lead to claim denial and recoupment of previously paid amounts in accordance with applicable State and Federal regulations.
- All services remain subject to post-payment review even when prior authorization was obtained.
- Denial risk increases when required documentation or prior authorization is missing or insufficient.
- Providers may be responsible for repayment (recoupment) if services are determined not medically necessary on retrospective review.
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