CurrentBlue Cross Blue Shield - TexasPolicy N/A

Pa Codes Fully Insured Certain Aso 01012026 Tx

Part 1 of a multi-part Blue Cross Blue Shield Texas list of CPT/HCPCS codes associated with services/categories for which prior authorization may be required for Fully Insured and certain ASO accounts; includes managing entity (Carelon) and effective/updates notes for some codes.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPa Codes Fully Insured Certain Aso 01012026 Tx

Policy CodePolicy N/A

Change TypeCode additions, removals, and routing/vendor assignment updates (effective dates noted)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must obtain prior authorization for listed services from the assigned reviewer (Carelon, Alacura, or BCBSTX) and verify member benefits prior to service.

SourceLink

POLICY UPDATE CHANGES

Multiple codes (e.g., 70471, 70472, 0628U, 0630U, 77436-77439, 70473) marked 'Add effective 7/1/2026' or 'Add effective 4/1/2026' where noted.

81354 marked 'Add effective 4/1/2026'.

81524 marked 'Add effective 4/1/2026'.

Multiple codes have 'Add effective' or 'Remove effective' dates noted (e.g., additions effective 1/1/2026 or 4/1/2026; removals effective 4/1/2026 or 7/1/2026).

Carelon will review requests for oncology drugs supported by an oncology diagnosis; BCBS will review if not associated with an oncology diagnosis.

Multiple add/remove/reassignment actions with effective dates listed in revision history (e.g., additions effective 01/01/2025, 04/01/2026, removals effective 04/01/2026 and 01/01/2026).

Addition of several Q- and J-codes to be reviewed by Carelon with effective dates (e.g., Q5157/Q5158/Q5159 effective 1/1/2026; Q5160/Q5161/Q5162 effective 4/1/2026).

Removal of certain behavioral health testing CPT codes effective 4/1/2026 (96105, 96110, 96112, 96113, 96116, 96121, 96125, 96127, 96130-96133, 96136-96139, 96146).

90870 (ECT) marked 'Remove effective 1/1/2026'.

~220Codes listed in part (approx)

CarelonPrimary UM manager

AlacuraAlternate UM manager

SeveralCodes with future effective dates

SomeCodes with scheduled removal

Home InfusionMajor category focus

Policy overview & scope

This is a searchable code list (part of a multi-part series) of CPT/HCPCS/U/Q/S codes for services and categories for which prior authorization may be required as of 1/1/2025–2026. Presence of a code on the list does not guarantee coverage — member benefits and contract terms determine coverage — and providers must verify eligibility and benefits before rendering services. The list shows assigned utilization management reviewers and routing (for many codes the reviewer is Carelon, with other mappings to Alacura or BCBSTX/Blue Approvr) and includes update notes with effective or removal dates where noted.

Policy metadata and scope summary

PolicyPa Codes Fully Insured Certain ASO 01012026 TX

StatusCURRENT

Primary UM managerCarelon

Alternate UM managersAlacura, BCBSTX (Blue ApprovrSM)

Last review2026-04

Scope summaryPart 1 list of CPT/HCPCS codes mapping prior‑authorization routing for Fully Insured and certain ASO accounts — code presence does not guarantee coverage; follow member contract and benefits.

NotePresence on list ≠ coverage; verify member benefits

Prior authorization mapping & routing rules

Prior authorization requirement mapping

Codes listed are associated with services/categories for which prior authorization may be required; presence on list does not guarantee coverage

ALL of the following

Carelon Prior Authorization for Unclassified / J3490 / J9011 / Q-codes — prior authorization required through Carelon (Carelon phone 1-866-455-8415). Note: These unclassified/drug codes are routed to Carelon for review; follow Field1–Field4 annotations per code and the Carelon mapping and removal effective dates.
Home infusion per diem codes are routed to BCBSTX for prior authorization review — do not submit to external vendors unless instructed.
Air ambulance services are routed to Alacura for prior authorization and review (Alacura phone 1-866-671-4834).
Molecular genetic testing (including specified U-codes such as 0628U, 0630U and other panel codes) is routed to Carelon — adhere to panel minimum gene counts and required gene lists; list separately in addition to primary procedure when indicated.

Code lists and vendor assignments

Billing Rule

Observe vendor assignment per code

Claims and prior authorization requests must be routed to the mapped reviewer (Field 3 value) shown for each code. Many codes list "3 = Carelon" — route those to Carelon Medical Benefits Management. Examples of major categories routed to Carelon: molecular genetics U- and CPT codes, many J/Q drugs and biosimilars, advanced imaging/radiology and cardiology procedures. Alacura handles medical transportation (e.g., A0430, S9960). BCBSTX handles certain home infusion per-diems and related S-codes (e.g., S9538).

Route codes with Field 3 = 3 to Carelon Medical Benefits Management
Alacura: medical transport codes such as A0430, S9960
BCBSTX: home infusion per-diem S9538 and related S-codes

Billing Rule

Effective / removal dates affect authorization and billing

Honor the 'Add effective' / 'Remove effective' annotations on code entries when determining authorization and billing responsibility. Check Field 4 for date notes on each code entry.

Actionable billing and documentation rules

Prior Authorization

Obtain prior authorization for listed codes

Providers must obtain prior authorization for services listed as requiring prior authorization. Management/authorization may be handled by Carelon or Alacura as indicated and via Blue Approvr or the phone number on the member ID card.

use assigned reviewer (Carelon/Alacura/BCBSTX) and Blue Approvr portal / member ID phone number

Documentation Required

Verify member benefit and contract

Presence of a code on this list does not guarantee coverage. Providers must verify member-specific benefits and contract exclusions prior to service.

Verify eligibility and benefits via Availity/vendor portal or call the phone number on the member ID card

Key terms & field mapping

Definitions and key terms

CarelonExternal molecular testing/utilization management vendor handling genetic test authorizations; many codes mapped '3 = Carelon' in code listings

Blue ApprovrSMBCBSTX internal routing/authorization program referenced for initiating prior auth requests and code mappings

AlacuraExternal vendor handling medical transportation/air ambulance authorizations (e.g., A0430, S9960) — call 1-866-671-4834

U-code / Category III / PLAU-codes and Category III/PLA entries (U/0001U etc.) are listed for molecular/genetic tests; some annotated with 'Add effective' dates and routed to Carelon

Field 1-4 mapping explanationField 1 = category/site of care; Field 2 = code description/drug; Field 3 = reviewer/vendor (eg '3 = Carelon' or '3 = BCBSTX' or '3 = Alacura'); Field 4 = operational notes (routing, 'Add/Remove effective' dates).

Fully Insured members note (TDI)

Code descriptor & panel requirements (operational guidance)

Code Descriptor / Panel Requirements

Each CPT code is listed with: category 'Molecular Genetic Lab Testing' or 'Molecular Pathology Procedure Level X', a short test description, and payer assignment.

Code descriptor repeating entry: Each line item presents:

,  = . ,  =  (sometimes with test type details such as 'Full Gene Sequence', 'Targeted Sequence Analysis', 'Common Variants', 'Duplication/Deletion Analysis', 'Panel Must Include Sequencing Of At Least N Genes').

represents repeated CPT entries in the document

Panel minimum gene requirements: Panel codes specify minimum gene lists or counts (example: 81410 requires sequencing of at least 9 genes including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK)

preserve explicit panel requirements

Effective date notes

`Document change timeline`

7/1/2026Add effective

Multiple advanced imaging/molecular codes (examples: 70471, 70472, 0628U, 0630U, 77436-77439) marked 'Add effective 7/1/2026' or 'Add effective 7/1/2026' where noted

4/1/2026Add effective

Several CT/advanced imaging and molecular codes (example: 70473, 70473 add effective 4/1/2026; 70473/70473 group) and specific lab/test codes noted as 'Add effective 4/1/2026'

4/1/2026Add effective

CPT 81354 (optical genome mapping) marked 'Add effective 4/1/2026'

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPa Codes Fully Insured Certain Aso 01012026 Tx

Policy CodePolicy N/A

Change TypeCode additions, removals, and routing/vendor assignment updates (effective dates noted)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must obtain prior authorization for listed services from the assigned reviewer (Carelon, Alacura, or BCBSTX) and verify member benefits prior to service.

SourceLink

On This Page

Policy overview & scopePrior authorization mapping & routing rulesCode lists and vendor assignmentsActionable billing and documentation rulesKey terms & field mappingCode descriptor & panel requirements (operational guidance)Document change timeline

Per-diem and unit definitions: per-diem codes represent a single daily rate; do not report conflicting per-diem codes together for the same date(s) of service.

Unit conversion requirements: for enteral/parenteral nutrition and similar services, convert billed quantities to the unit definition required by the payer (follow the unit conversion requirements published by BCBSTX/Carelon).

Do not report S9810 concurrently with per-diem infusion codes; S9810 should not be billed with conflicting per-diem codes.

Use specified CPT/HCPCS code with descriptor exactly as required; when a procedure has a required CPT code and descriptor, include it per payer mapping guidance.

Code effective/remove dates: observe effective dates (example: codes added with effective 7/1/2026) and removal dates; some codes have vendor-assignment or vendor-removal effective dates — follow those dates when submitting prior authorization requests.

Prior Authorization through Carelon for Unclassified Codes: when a service is listed as Unclassified or billed under J3490/J9011/Q-codes, obtain prior authorization from Carelon and include all Field1–Field4 annotations (Field1: site of care; Field2: drug description; Field3: reviewer; Field4: operational notes including effective/add/remove dates).

Behavioral health services: behavioral health program credentialing requirements and behavioral health service prior authorization rules apply where indicated — follow vendor assignment and any credentialing prerequisites.

Review Routing / Prior Authorization Responsibility

ALL of the following

Field1 = Site of care category (e.g., inpatient, outpatient, home infusion, air ambulance).
Field2 = Drug / service description (e.g., unclassified drug J-codes, molecular genetic panel descriptors, enteral/parenteral nutrition).
Field3 = Reviewer assignment: either Carelon (Carelon phone 1-866-455-8415), Alacura (Alacura phone 1-866-671-4834), or BCBSTX — follow the mapping per code.
Field4 = Operational notes: include effective/add/remove dates, vendor mapping and removal effective dates, routing instructions (e.g., Home infusion per diem -> BCBSTX; Air ambulance -> Alacura), and any unit conversion or billing rules (do not report S9810 with per-diem codes; do not combine conflicting per-diem codes).

Prior AuthorizationPrior Authorization Required
Providers must obtain prior authorization for codes listed on this file and must submit requests to the assigned reviewer (Carelon / Alacura / BCBSTX) as indicated. Presence on this list is not coverage — verify member contract and effective dates before providing services.
Carelon (prior authorization administrator for many molecular genetic tests, unclassified drug codes, radiation and advanced imaging additions): 1-866-455-8415
Alacura (air ambulance and assigned services): 1-866-671-4834
Home infusion per-diem codes are routed to Blue Cross Blue Shield of Texas (BCBSTX) for prior authorization
Effective date exceptions: observe effective/add/remove dates for newly added codes (example: multiple codes added effective 7/1/2026)
Per-diem and unit definitions must be followed; do not bill conflicting per-diem codes together
Unit conversion requirements apply for enteral/parenteral nutrition — convert billed quantities to payer-prescribed units
Do not report S9810 with per-diem codes
Follow Field1–Field4 annotations per code; include site of care, drug description, reviewer and operational notes with requests
Adhere to molecular genetic testing requirements: use specified CPT/HCPCS/U-code with descriptor, meet panel minimum gene counts and required gene lists, and list tests separately in addition to primary procedure when indicated
Follow payer mapping: code-to-vendor routing (Carelon/Alacura/BCBSTX) and Blue ApprovrSM as applicable
Behavioral health: ensure program credentialing requirements are met and obtain behavioral health prior authorization where required
Presence on list is not coverage — verify member contract and benefits before delivering services

70471 / 70472 / 70473 — additions noted (examples: add effective 7/1/2026 or 4/1/2026 as indicated)
81354 — added 4/1/2026
81524 — added 4/1/2026
J-code additions effective 1/1/2026 and removals effective 4/1/2026 (example: J1562 removal 4/1/2026)
Behavioral health testing CPT removals effective 4/1/2026; 90870 removed 1/1/2026
Always check Field 4 date notes on each code entry

Billing RulePer-diem & unit billing rules
Per-diem and unit billing rules: bill per the unit or per-diem mapping in the list (e.g., enteral/parenteral units and home infusion per-diems). Do not combine per-diem codes with conflicting hourly or other per-diem codes; follow the specific billing constraints in the code entries.
Per-diem/unit examples: B4103 (500 ml = 1 unit), B4149/B4150 (100 kcal = 1 unit), B4164 (500 ml = 1 unit)
Do not use S9810 (per hour) with any per-diem code
Do not use S9208 or S9211 etc. with home infusion per-diem codes
Home infusion per-diems routed to BCBSTX: S9538, S9542, S9558, S9559, S9560, S9562, S9590, S9810

Prior AuthorizationVendor-specific contacts
Contact the assigned vendor for prior authorization per the code mapping. Use the vendor phone number or the Blue Approvr portal as applicable when routing PA requests.
Carelon: 1-866-455-8415
Alacura: 1-866-671-4834
Use Blue Approvr/portal where applicable

Billing RuleSelect codes with immediate effective/ removal notes
Some individual codes have immediate Add/Remove effective notes that change billing/authorization. Respect those date annotations when submitting PAs or claims.
95965 and 95966: Add effective 1/1/2026
0042T: Remove effective 4/1/2026
81354 and 81524: Add effective 4/1/2026
Behavioral health testing CPT removals (96105, 96110, 96112, 96113, 96116, 96121, 96125, 96127, 96130-96133, 96136-96139, 96146) noted Remove effective 4/1/2026

'TDI' will be indicated on the member's ID card for Fully Insured Members effective 1/1/2026; presence on list may not equal coverage — verify benefits

Provider Administered Drug Therapy categoryCategory for drugs administered by providers/infusions; many J/Q codes mapped to Carelon or BCBSTX for prior authorization; unclassified drugs (J3490/J9011/J0642 etc.) require prior authorization through Carelon as noted

81354 note: 81354: Add effective 4/1/2026

source shows 81354 with add effective 4/1/2026

81524 note: 81524: Add effective 4/1/2026

source shows 81524 with add effective 4/1/2026

Payer assignment note: Certain codes include explicit payer mapping (eg '3 = Carelon') indicating management vendor assignment

use for routing and PA assignment

Documentation RequiredPanel minimum gene count and required gene lists
Labs billing panel CPT codes must meet the code-specific 'must include' gene lists and minimum gene counts. When requesting prior authorization, attach the laboratory report showing which genes are included and the panel size to demonstrate compliance with the code descriptor.
Example panel codes with minimums: 81410, 81418, 81419, 81430, 81439/81440, 81470, 81471, 81432, 81434, 81435
Attach laboratory report showing included genes when requesting prior authorization

4/1/2026Add effective

CPT 81524 (CNS tumor DNA methylation analysis) marked 'Add effective 4/1/2026'

1/1/2026Add effective

Multiple J/Q drug codes added effective 1/1/2026 (examples: J0174, J0175, J0218, J0225, J2329, J9333, J9334, J9376)

4/1/2026Remove effective

Certain J/Q drug and biosimilar entries scheduled for removal or reassignment (example: J1562 'Remove effective 4/1/2026'; Q5109 'Remove effective 4/1/2026')

1/1/2026Add effective

Numerous Q-code biosimilar additions assigned to Carelon effective 1/1/2026 (examples: Q5157/Q5158/Q5159 additions noted effective 1/1/2026)

4/1/2026Remove effective

Behavioral health testing CPT codes listed for removal: 96105, 96110, 96112, 96113, 96116, 96121, 96125, 96127, 96130-96133, 96136-96139, 96146 marked 'Remove effective 4/1/2026'

1/1/2026Remove effective

Electroconvulsive therapy code 90870 marked 'Remove effective 1/1/2026'

effective date noted in tableOperational noteLatest

Updates column used to schedule additions/removals and to assign review routing (Carelon/BCBSTX/Alacura); presence on list does not guarantee coverage