Prior Authorization Requirements for Outpatient and Select Services
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This document lists services and service categories that require prior authorization for fully insured and certain ASO groups of Blue Cross Blue Shield of Texas; it affects providers submitting authorization requests and verifying benefits. It covers outpatient medical/surgical services, select specialty services, home-based services, mental health/substance use disorder services, and pharmacy/administered drug reviews.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Covered When Prior Authorization Obtained
Services and service categories requiring prior authorization for Fully Insured & certain ASO groups effective 01/01/2024 include:
Exact CPT/HCPCS codes are provided separately on the provider portal; management of prior authorization may be split between Carelon and BCBSTX.
Not all prior authorization requirements in this document apply to every Blue Cross Blue Shield of Texas product. Providers must confirm product-specific rules for the member being treated (for example, members in an HMO Limited Provider Network must be referred to providers within that same limited network). Always verify eligibility and benefits through the insurer’s provider tools before scheduling services.
This policy does not list explicit medical-necessity denial rules. Instead, medical necessity determinations reference evidence-based clinical guidelines and external criteria (for example, MCG and other recognized sources) used during clinical review. Providers should expect the utilization review process to rely on those guidelines rather than on discrete denial statements in this administrative listing.
Imaging and Outpatient Procedures Requiring Authorization
Imaging and select outpatient procedures
No modality-specific clinical criteria provided in this document; refer to provider portal for exact procedure codes and management assignment (Carelon vs BCBSTX).
Procedure and Drug Coding / Authorization Notes
| Note indicates codes not available in the document and that downloadable lists exist on provider site |
Provider Responsibilities and Authorization Workflow
Obtain prior authorization for listed outpatient services
Prior authorization is required for the outpatient medical/surgical services and select programs listed in this policy; management of these authorizations may be split between Carelon Medical Benefits Management and BCBSTX. Providers must refer to downloadable code lists and the provider website for the exact procedure codes that require authorization.
- Services listed include molecular genetic lab testing, musculoskeletal/joint and spine surgery, radiation oncology, selected outpatient services, sleep, cardiology lipid apheresis, ENT, gastroenterology, outpatient surgery, neurology, pain management, sleep studies, wound care, home infusion therapy, non-emergent air ambulance, transplant services and evaluations, out-of-network elective outpatient surgery, dialysis from out-of-network providers, specialty pharmacy medications covered by medical benefits, and provider-administered drug therapies.
- Exact CPT/HCPCS codes and modality-specific lists are available for view/download on the provider site; some services are managed by Carelon while others are managed by BCBSTX.
Check drug prior authorization and step therapy requirements
Some provider-administered medications and specialty pharmacy drugs require prior authorization and may be subject to step therapy; providers must check the drug list guide and Prior Authorization/Step Therapy program details on the provider site to determine requirements for a specific drug.
- Prior Authorization is required on some medications before coverage under Pharmacy Benefits — consult the drug list guide.
- Provider-administered drug therapy reviews follow BCBSTX medical policy screening criteria and may require medical necessity review.
Verify eligibility and request clinical review promptly
Verify member eligibility, benefits, and whether prior authorization is required using Essentials/Utilization Management resources; for unplanned inpatient admissions, seek Clinical Review within 48 hours to avoid post-service medical necessity reviews.
- Use the Utilization Management page on the provider website and Essentials to determine product-specific requirements.
- Seek Clinical Review within 48 hours of admission for all unplanned inpatient hospital care (surgical, non-surgical, mental health and/or substance use disorder).
Risk of adverse determination if authorization not obtained
Failure to verify eligibility/benefits and to obtain required prior authorization or timely Clinical Review may result in adverse determinations or post-service medical payment denials.
- Providers should confirm authorization requirements before service to reduce risk of post-service medical necessity reviews and adverse determinations.
Authorization Management and Portal Details
Prior authorization required for imaging and select outpatient procedures
Prior authorization is required for imaging and other select outpatient procedures as listed in this policy; exact thresholds, modality‑level rules and the specific CPT/HCPCS code lists are available for view or download on the provider portal.
- Imaging and select outpatient services included in the list may require prior authorization; consult provider resources for exact indications and codes.
- The policy notes downloadable procedure code lists for Fully Insured and certain ASO groups — codes are not listed in this document.
Contrast and Modality-Specific Authorization
Consult provider portal for contrast and modality‑specific prior authorization rules
Select outpatient services including imaging may require prior authorization and may have modality‑ or code‑level contrast/administration rules; consult the provider portal for specific modality and code‑level requirements.
- Contrast and infusion site‑of‑care rules (for infusion therapies) and other modality‑specific requirements are maintained on the provider site or managed through Carelon as indicated.
- Refer to provider resources to determine if a given imaging procedure or outpatient service requires authorization and whether contrast rules apply.
Policy Purpose and Scope
Background: This is an administrative prior authorization policy that identifies categories of services and programs that require prior authorization for Fully Insured and certain ASO groups effective 01/01/2024. It enumerates service groups (for example, advanced imaging, cardiology, home health, home infusion, transplant evaluations, mental health and substance use disorder outpatient programs, and selected outpatient medical/surgical services) rather than providing clinical treatment criteria. Management of listed services may be split between Carelon and BCBSTX; exact procedure and code-level requirements are maintained on the provider website and downloadable code lists.
Definitions and Reference Documents
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