CurrentBlue Cross Blue Shield - TexasPolicy N/A

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

Defines prior authorization, notification, and medical necessity requirements for Medicare Advantage medical, surgical, and behavioral health services for Blue Cross and Blue Shield of Texas members; includes use of eviCore for specific service categories and applies to in-network and out-of-network providers as specified.

Policy Summary

PayerBlue Cross Blue Shield - Texas

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

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateJan 9, 2025

Key ActionObtain prior authorization through eviCore for specified service categories and secure prior authorization before elective inpatient admissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-04-01eviCore start

877-774-8592BCBSTX PA phone

1 business dayEmergency notification

elective requires PAInpatient PA rule

2025-01-09

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Coverage and Medical Necessity Criteria

Inpatient authorization and medical necessity requirements

Covered only when administrative and clinical conditions are met:

Prior Authorization for Elective Inpatient Admissions: All planned (elective) inpatient hospital care requires prior authorization before the admission occurs.

Includes surgical, non-surgical, behavioral health and substance abuse admissions.

Notification for Unplanned Inpatient Admissions: All unplanned inpatient hospital care requires notification within one business day of admission.

Includes surgical, non-surgical, behavioral health and substance abuse admissions.

Post-Acute and Residential Admissions: Prior authorization is required for admissions to skilled nursing facilities, long term acute care hospitals, rehabilitation facilities, and residential treatment programs.

Medical Necessity Requirement: Medical necessity must be met for all services regardless of prior authorization requirement; services are subject to retrospective review and recoupment.

Out-of-network providers are required to obtain prior authorization for all services. Exceptions to this prior authorization requirement include emergency services, emergency ambulance services, stabilization, and services provided by Indian Health Services.

Medical necessity must be met for all services regardless of whether prior authorization was obtained. Services that do not meet medical necessity criteria are subject to retrospective review and recoupment in accordance with applicable State and Federal rules and regulations.

Codes and Billing Examples

Covered CPT CodesCPTCovered

55970	Intersex Reassignment Surgery
55980	Intersex Reassignment Surgery

Provider Responsibilities and Prior Authorization Workflow

Prior Authorization

Procedure Code Grid Prior Authorization Requirements

Many specific procedures and services require prior authorization. Providers must consult the comprehensive procedure code grid/prior authorization list to determine authorization requirements before rendering services.

Includes but not limited to: bariatric surgery; blepharoplasty; botulinum toxin injections; chemotherapy and radiation therapy; DME, orthotics and prosthetics; laboratory, imaging and other diagnostic tests (PET, MRA, MRI, CT); home health; injections; minor surgeries; organ transplants and pre-transplant evaluations; special rehabilitation services (PT/OT/ST, cardiac/pulmonary rehab); long term acute care; skilled nursing facility and residential treatment admissions; nutritional products/services; certain behavioral health services.
All transplants and pre‑transplant evaluations require prior authorization.
For eviCore-managed services (radiology, molecular genetics, musculoskeletal/spine/joint/pain, sleep, specialty drugs), follow eviCore prior authorization processes and contact points.

Prior Authorization

Out-of-Network Provider Prior Authorization Requirements and Exceptions

Out-of-network providers are required to obtain prior authorization for services except in limited circumstances. Failure to request prior authorization when required may result in claim denial or reduced payment, subject to the exceptions listed below.

Exceptions where prior authorization by an out-of-network provider is not required: emergency services, emergency ambulance services, stabilization services, and services provided by Indian Health Services.
Network exceptions (out-of-plan or out-of-network due to network adequacy) may still require authorization per the procedure code grid; check the grid for program-specific rules and eviCore-managed services.