Prior Authorization requirements for Medicare Advantage services
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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; affects in-network and out-of-network providers serving BCBSTX Medicare Advantage members.
No material clinical or coverage changes in this revision.
Coverage Criteria and Exceptions
General authorization criteria
Covered when prior authorization and medical necessity requirements are satisfied as follows:
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Chunks 5 and 3
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Exceptions to the prior authorization requirement include emergency services, emergency ambulance services, stabilization, and services provided by Indian Health Services. These services do not require prior authorization when delivered under the described emergency or IHS circumstances.
Services that do not meet medical necessity criteria are subject to retrospective review and potential recoupment in accordance with state and federal rules and regulations. Payment for services provided that fail to demonstrate medical necessity may be denied after review.
Procedure Codes and Coding Guidance
Provider Responsibilities and Authorization Process
Prior Authorization Required — eviCore and Inpatient Admissions
Prior authorization is required for services managed through eviCore and for all planned (elective) inpatient hospital care and for all inpatient stays as specified below. Providers should initiate authorization requests through the eviCore Healthcare Web Portal or by calling eviCore. For eviCore: call toll-free 1-855-252-1117 between 7 a.m. and 7 p.m. local time Monday–Friday (TX only: 6 a.m.–6 p.m. CST Monday–Friday and 9 a.m.–noon CST on weekends and legal holidays). For Blue Cross and Blue Shield of Texas prior authorization inquiries: call toll-free 1-877-774-8592 between 8 a.m. and 8 p.m. CST Monday–Friday except holidays. Using the eviCore Healthcare Web Portal is the most efficient way to initiate a case, check status, review guidelines, view authorizations and eligibility, and access the comprehensive prior authorization procedure code list.
- All planned (elective) inpatient hospital admissions require prior authorization and must be authorized before the admission occurs.
- All inpatient stays (including medical, surgical, behavioral health, and substance abuse) require prior authorization as specified; unplanned inpatient care requires notification within one business day of admission.
- Certain services (radiology, molecular genetics, musculoskeletal/spine/joint/pain, sleep, specialty drugs and other services listed in the procedure code list) are managed through eviCore and require prior authorization effective 2025-01-01.
- Providers may view the full list of services and specific procedure codes requiring prior authorization on the BCBSTX Clinical Resources Prior Authorizations and Predeterminations page under Blue Cross Medicare Advantage PPO and HMO.
- Network exceptions (out-of-plan or out-of-network due to network adequacy) follow the same prior authorization requirements; refer to the procedure code list for details.
Procedure-Specific Prior Authorization
Certain surgeries and specific procedures require prior authorization through the procedure code list. Intersex reassignment surgery codes (CPT 55970, 55980) require prior authorization.
- All surgeries (including pre- and post-operative care, assistant surgeon, anesthesiologist) and organ transplants require prior authorization; all transplants and pre-transplant evaluation require authorization.
- Intersex reassignment surgery (CPT 55970, 55980) = Prior authorization required.
- Refer to the comprehensive prior authorization procedure code list to determine whether a given procedure code requires review.
How to Request Authorization
Providers must use the eviCore Healthcare Web Portal or call eviCore to initiate prior authorization requests and to check authorization status. The portal provides access to guidelines, authorizations, eligibility, and the searchable list of procedure codes requiring review.
- eviCore Healthcare Web Portal is the preferred method to initiate a case, check status, and review guidelines.
- Call eviCore toll-free at 1-855-252-1117 for portal assistance and to initiate or check authorizations.
- BCBSTX prior authorization phone assistance: 1-877-774-8592 for Medicare Advantage prior authorization rules when directed to Blue Cross and Blue Shield of Texas.
Denial and Retrospective Review Risk
Medical necessity must be met for all services regardless of whether prior authorization was required. Services provided without required prior authorization or services that do not meet medical necessity are subject to retrospective review and possible denial or recoupment in accordance with state and federal rules.
- A prior authorization or pre-certification does not guarantee payment; benefits are determined when the claim is adjudicated based on member eligibility and certificate of coverage on the date of service.
- All services are subject to retrospective review and potential recoupment if documentation does not support medical necessity or required prior authorization was not obtained.
Definitions and Notification Requirements
Background and Policy Principles
Medical necessity must be demonstrated for all services regardless of whether prior authorization was required or obtained. All services remain subject to retrospective review, and those found not to meet medical necessity criteria may be subject to recoupment per applicable regulations.
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