Pa Codes Fully Insured Certain Aso 01012026 Tx
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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.
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'.
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.
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).
- 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).
- 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 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
Code lists and vendor assignments
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).
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.
- 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
Actionable billing and documentation rules
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
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
Per-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
Vendor-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
Select 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.
Key terms & field mapping
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.
, = . , = (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
preserve explicit panel requirements
Effective date notes
use for routing and PA assignment
Panel 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.
Document change timeline
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
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'
CPT 81354 (optical genome mapping) marked 'Add effective 4/1/2026'
CPT 81524 (CNS tumor DNA methylation analysis) marked 'Add effective 4/1/2026'
Multiple J/Q drug codes added effective 1/1/2026 (examples: J0174, J0175, J0218, J0225, J2329, J9333, J9334, J9376)
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')
Numerous Q-code biosimilar additions assigned to Carelon effective 1/1/2026 (examples: Q5157/Q5158/Q5159 additions noted effective 1/1/2026)
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'
Electroconvulsive therapy code 90870 marked 'Remove effective 1/1/2026'
Updates column used to schedule additions/removals and to assign review routing (Carelon/BCBSTX/Alacura); presence on list does not guarantee coverage
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