BlueCard^® Prior Authorization Requirements

As a PPO/POS, HMO or Traditional contracted provider with Blue Cross and Blue Shield of Texas, you are responsible for the completion of the prior authorization process for BlueCard members.

How to Determine Requirements:

• Telephone: Call the BlueCard Eligibility line at 1-800-676-2583 and ask to be transferred to the Medical Management Department.
• Electronic: Use the Pre-Cert/Pre-auth Router (out-of-area members) to view the applicable Blue Plan's medical policy or general pre-certification/prior authorization information. If pre-certification/prior authorization is required, submit an electronic request (278 transaction) through Availity or your preferred web vendor portal.

Note:

• Contact the Plan that issued the prior authorization with updated or clinical information as necessary if there is a change in the patient status from the original prior authorization.
• The prior authorization must cover the entire date span and all services submitted on the claim to avoid requests for additional information and possible delays or denials.
• Failure to prior authorize may result in reduced payment or denial and health care providers cannot collect these fees from the members. Out-of-network services require prior authorization.

Group Specific Information

• Outpatient Advanced Diagnostic Imaging Services for HMA Members Require Authorization –

  To obtain authorization for outpatient advanced diagnostic imaging services for HMA (prefix HHM) members call 1-888-376-6544.

• Medicare Advantage Product Update: Identifying Michigan Public School Employees Retirement System Members

  Remember prior authorization is required for Michigan Public School Employees Retirement System (MPSERS) – Prefix XYO members for:

  • Acute care admissions
  • Skilled nursing admissions
  • Inpatient rehabilitation admissions
  • Radiology services
• Imaging Program for The Boeing Company Members

  The Boeing Company, in partnership with American Imaging Management^® (AIM^®), implemented a Radiology Quality Initiative (RQI) program for all of its members. RQI is a prospective clinical review program for outpatient advanced diagnostic imaging services Participating members can be identified by the three-character prefixes ('BHP', 'BYR', 'BEM', 'BCU') that appear on their member ID cards. The diagnostic imaging studies covered under this program include the following:

  • Computed Tomography (CT/ CTA)
  • Magnetic Resonance Imaging (MRI/MRA)
  • Nuclear Cardiology
  • Positron Emission Tomography (PET)

  Refer to the RQI page on the provider website for more information.

AIM Specialty Health (AIM) is an operating subsidiary of WellPoint, Inc.