CurrentBlue Cross Blue Shield - TexasPolicy N/A

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

Governs prior authorization processes and requirements for Blue Cross and Blue Shield of Texas Medicare Advantage medical, surgical, and behavioral health services, including which services require prior authorization and vendor contacts; applies to providers delivering care to 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 TypeBehavioral health vendor transition (Magellan → BCBSTX) + eviCore routing clarified

Effective DateOct 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization through eviCore (or contact BCBSTX for behavioral health after 01/01/2024) using the eviCore portal or designated phone numbers.

SourceLink

POLICY UPDATE CHANGES

Effective January 1, 2024, Magellan will no longer be contracted with BCBSTX for Behavioral Health services; providers should contact BCBSTX directly for BH prior authorization after that date.

Prior authorization requirements are effective 10/01/2023 and identify eviCore as the utilization management vendor for many service types.

10/01/2023Prior auth effective

01/01/2024BH vendor change

1-877-774-8592BCBSTX phone

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1-800-327-9251Magellan phone (through 2023)

Coverage Criteria and Medical Necessity

Administrative prior authorization and medical necessity requirements

Covered when ALL of the following administrative criteria are met

Planned inpatient admissions: Prior authorization is required before elective/planned inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse).

Failure to obtain prior authorization may result in denial.

Unplanned (emergency) admissions: For unplanned (emergency) inpatient admissions, notification to the payer is required within one business day of admission.

Exceptions: emergency services, emergency ambulance services, stabilization, and services provided by Indian Health Services are not subject to the out-of-network prior authorization requirement.

Other facility admissions requiring authorization/notification: Admissions to skilled nursing facilities, long term acute care hospitals (LTACH), rehabilitation facilities, and residential treatment programs require authorization or notification as specified.

Follow prior authorization timing rules for planned versus unplanned admissions.

Medical necessity: All services must meet medical necessity criteria; services are subject to retrospective review and recoupment in accordance with state and federal rules and regulations.

Preauthorization does not guarantee payment.

Out-of-network providers are required to seek prior authorization for all services; however, there are explicit exceptions. Prior authorization is not required for emergency services, emergency ambulance services, services necessary for stabilization, and services provided by Indian Health Services.

All services must meet medical necessity standards regardless of whether prior authorization was obtained. Services determined not to meet medical necessity may be denied and are subject to retrospective review and recoupment in accordance with applicable state and federal rules and regulations.

Procedure and Billing Codes

Explicit procedure codes listedCPTCovered

55970	Intersex Reassignment Surgery
55980	Intersex Reassignment Surgery

Provider Responsibilities and Authorization Routing

Prior Authorization

Prior Authorization Required — eviCore Managed Services

Providers must obtain prior authorization through eviCore for specified service categories. Use the eviCore Healthcare Web Portal to initiate cases, check status, review guidelines, and view authorizations and eligibility. For categories listed below, follow eviCore submission procedures or call the vendor phone number when directed.

Radiology (including PET, MRA, MRI, CT)
Medical Oncology
Molecular Genetics (eviCore portal or phone)
Musculoskeletal – Spine/Joint/Pain (call eviCore 1-855-252-1117, 7 a.m.–7 p.m. local time M–F)
Radiation Therapy
Sleep (TX only; portal/phone availability per eviCore hours)
Specialty Drug management

Prior Authorization

Behavioral Health Prior Authorization Vendor Transition

Behavioral health prior authorization vendor will transition. Providers requesting Behavioral Health services for Blue Cross Medicare Advantage HMO and HMO SNP must contact Magellan Healthcare at 1-800-327-9251 for prior authorization through 12/31/2023. Effective 01/01/2024, Magellan will no longer be contracted; contact Blue Cross and Blue Shield of Texas at 1-877-774-8592 for prior authorization instructions.

Key Terms and Vendors

eviCore (vendor)

Vendor nameeviCore (eviCore healthcare, LLC)

RoleProvides utilization review and prior authorization routing for select health care services on behalf of Blue Cross and Blue Shield of Texas.

Trademark noteeviCore® is a trademark of eviCore healthcare, LLC, formerly known as CareCore.

Relationship to BCBSTXIndependent third‑party vendor; BCBSTX makes no endorsement, representations or warranties regarding vendor products or services.

Use in policyReferenced as the utilization management vendor for specified Medicare Advantage medical, surgical, and behavioral health prior authorization routing.

Policy Background

This is an administrative policy that defines utilization management routing and prior authorization requirements for Medicare Advantage medical, surgical, and behavioral health services. It outlines when prior authorization is required (for example, for planned elective inpatient admissions), the timing for notification of emergency admissions, and emphasizes that all services must meet medical necessity. Preauthorization requirements and routing are operational instructions and do not constitute clinical treatment guidance; obtaining prior authorization does not guarantee payment, as benefits and payment are ultimately determined at claim adjudication.

Policy Summary

PayerBlue Cross Blue Shield - Texas

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

Policy CodePolicy N/A

Change TypeBehavioral health vendor transition (Magellan → BCBSTX) + eviCore routing clarified

Effective DateOct 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization through eviCore (or contact BCBSTX for behavioral health after 01/01/2024) using the eviCore portal or designated phone numbers.

SourceLink

On This Page

Magellan Healthcare prior auth for BH services through 12/31/2023: 1-800-327-9251
Effective 01/01/2024 BH prior authorization routing: BCBSTX Provider line 1-877-774-8592 (8 a.m.–8 p.m. CST M–F)

Prior Authorization

Listed Services Requiring Prior Authorization

Many common services require prior authorization — consult the comprehensive prior authorization grid/procedure code list for specific codes and requirements. Presence of a service on this list does not guarantee coverage; benefits are determined at claim adjudication. Examples of services commonly requiring prior authorization are listed below.

Bariatric surgery — Prior Authorization = Yes
Blepharoplasty — Prior Authorization = Yes
Botox injections — Prior Authorization = Yes
Chemotherapy and Radiation Therapy — Prior Authorization = Yes
Implantable devices — Prior Authorization = Yes
Home health care and IV services — refer to procedure code list
DME, orthotics, prosthetics — refer to procedure code list
LTAC (TX facilities reviewed through eviCore) — Prior Authorization = Yes
Skilled Nursing Facility admissions — Prior Authorization = Yes
Special rehabilitation services (PT/OT/ST, cardiac rehab) — Prior Authorization = Yes
All transplants and pre-transplant evaluations — Prior Authorization = Yes
Intersex reassignment surgery (55970, 55980) — Prior Authorization = Yes

Step Therapy

Step Therapy Not Specified in This Section

Step therapy requirements are not specified in this section. Refer to service-specific prior authorization grids, drug management policies, or benefit plan documents for any applicable step therapy or quantity limit programs.

No general step therapy rules listed here — check the drug-specific utilization management program and the prior authorization procedure code list for requirements

Prior Authorization

Admission Notification and Authorization Timing

Notification timing rules: planned (elective) inpatient admissions require prior authorization before the admission occurs. For emergency/unplanned inpatient admissions, notification is required within one business day of admission. Out-of-network providers must seek prior authorization for all services except emergency, emergency ambulance, stabilization, and Indian Health Services.

Planned elective inpatient hospital care (surgical, non-surgical, behavioral health, substance abuse) — prior authorization required before admission
Unplanned inpatient admissions — notify within one business day
Skilled nursing facility, LTACH, rehabilitation, and residential treatment program admissions — prior authorization required
Out-of-network providers must seek prior authorization for all services (exceptions apply)

Denial Risk

Medical Necessity and Retrospective Review

Medical necessity must be met for all services regardless of prior authorization status. All services are subject to retrospective review and potential recoupment if not medically necessary.

Services not meeting medical necessity criteria may be subject to retrospective review and recoupment
Preauthorization/precertification does not guarantee payment — final benefits determined at claim processing

Prior Authorization

Prior Authorization Required for Elective Inpatient and Out-of-Network Services

Prior authorization is required for elective inpatient services and many out-of-network services; failure to obtain required prior authorization may result in claim denial except for emergencies. Consult the prior authorization procedure code list and member benefit booklet to determine coverage and authorization requirements.

Elective inpatient and many out-of-network services require prior authorization
Emergencies are exceptions but require timely notification
Consult member benefit booklet or customer service to confirm coverage under a specific contract