CurrentBlue Cross Blue Shield - TexasPolicy N/A

Ma Priorauthlist 01012023

Defines prior authorization and notification requirements for Medicare Advantage medical, surgical, and behavioral health services managed by Blue Cross Blue Shield of Texas, including services requiring eviCore review, network exceptions, notification timing, and examples of services that typically require prior authorization. It directs providers to eviCore and BCBS TX web resources for specific procedure codes.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyMa Priorauthlist 01012023

Policy CodePolicy N/A

Change Typeclarified

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must obtain prior authorization for listed services through eviCore (portal or specified phone numbers/hours) effective 01/01/2023; specific services and codes are on the eviCore/BCBSTX prior authorization grid.

SourceLink

POLICY UPDATE CHANGES

Prior Authorization REQUIREMENTS through eviCore effective 01/01/2023.

eviCore-managedService Categories with eviCore Prior Auth

MultipleExamples of services requiring PA

SomeServices explicitly not requiring PA

Policy Summary

Prior Authorization & Coverage Rules

Prior Authorization via eviCore (Effective 2023-01-01)

Prior authorization requirements through eviCore for specific service categories; providers must use the eviCore portal or call lines as indicated.

threshold":"","note":""},{"operator":"all","n":0,"label":"Molecular Genetics","text":"Molecular Genetics prior authorization managed via eviCore (refer to portal URL).","threshold":"","note":""},{"operator":"all","n":0,"label":"Musculoskeletal (Spine/Joint/Pain)","text":"Musculoskeletal (Spine/Joint/Pain) prior authorization: call eviCore toll-free 1-855-252-1117 between 7 a.m. to 7 p.m. local time.","threshold":"","note":""},{"operator":"all","n":0,"label":"Radiation Therapy","text":"Radiation Therapy prior authorization: call eviCore Monday through Friday except holidays (hours not fully specified).","threshold":"","note":""},{"operator":"all","n":0,"label":"Sleep (TX only)","text":"Sleep prior authorization (TX only): call eviCore between 6 a.m. to 6 p.m. (CST) Monday through Friday.","threshold":"","note":""},{"operator":"all","n":0,"label":"Specialty Drug","text":"Specialty Drug prior authorization: contact eviCore (includes limited weekend and legal holiday morning hours per eviCore schedule).","threshold":"","note":""}]}

Network Participation and Exceptions

ALL of the following

Out-of-network prior authorization: Out-of-network providers must seek prior authorization for all services.
Exceptions (no prior authorization required for out-of-network): emergency services, emergency ambulance services, stabilization, and services provided by Indian Health Services.

Medical Necessity

Medical necessity requirement: Medical necessity must be met for all services regardless of whether prior authorization is required.

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

Inpatient Facility Admission Requirements

Elective inpatient admissions: Prior authorization is required for all planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse) before the admission occurs.

Unplanned inpatient admissions: For all unplanned inpatient hospital care, notification must be made within one business day of admission to the facility.

SNF/LTACH/rehabilitation admissions: All admissions to a skilled nursing facility, long term acute care hospital (LTACH) or a rehabilitation facility require prior authorization.

Residential treatment program admissions: All residential treatment program admissions require prior authorization.

Notification Requirements for Emergency Admissions

Emergency admission notification timing: In cases of an emergency, notification is required within one business day of admission.

Examples of Services and Prior Authorization Expectations

Presence of a service or code on the prior authorization list does not guarantee that the service is covered under a member’s benefits. Coverage and payment are determined when a claim is received and are based on the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.

Providers should refer to the eviCore/BCBSTX prior authorization grid and procedure code lists for specific procedure codes and authorization requirements; obtaining prior authorization does not assure payment.

Required Provider Actions & Billing Rules

Prior Authorization

Use eviCore for specified service categories

Providers must obtain prior authorization for the listed eviCore-managed service categories through eviCore effective 01/01/2023. Use the eviCore Healthcare Web Portal (most efficient) or call the designated eviCore phone lines. Consult the eviCore site for category-specific contact hours and details.

Portal: eviCore Healthcare Web Portal (see eviCore BCBS page)
Main phone: 1-855-252-1117
Consult eviCore site for category-specific hours and contact methods

Prior Authorization

Prior authorization required for elective inpatient admissions

Elective (planned) inpatient hospital admissions require prior authorization before the admission occurs. For unplanned (non-elective) inpatient admissions, providers must notify the plan within one business day of admission.

Prior Authorization

Notification timing for emergency admissions

For emergency inpatient admissions, providers must notify the plan within one business day of the admission.

Documentation Required

Medical necessity documentation and retrospective review

Providers must ensure medical necessity for all services. All services are subject to retrospective review and potential recoupment in accordance with State and Federal rules and regulations.

Documentation Required

Out-of-network providers must seek prior authorization

Out-of-network providers are required to request prior authorization for all services. Exceptions where prior authorization is not required include emergency services, emergency ambulance services, stabilization, and services provided by Indian Health Services.

Billing Rule

Prior authorization does not guarantee payment

Obtaining prior authorization or pre-certification does not guarantee payment. Final payment is determined at claim adjudication based on the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered.

55970	Intersex Reassignment Surgery
55980	Intersex Reassignment Surgery

OpenPayer

Ma Priorauthlist 01012023

Policy Summary

Prior Authorization & Coverage Rules

Examples of Services and Prior Authorization Expectations

Code Lists

Required Provider Actions & Billing Rules

Definitions

Document Changes