Utilization Management (Prior Authorizations & Predeterminations)

Utilization management is at the heart of how we can help members continue to access the right care, at the right place and at the right time. In this section, we will review the different types of reviews – Prior Authorization, Predetermination and Post-Service Review.

What is Utilization Management Review

A utilization management review determines whether a benefit is covered under the health plan using evidence-based clinical standards of care. Utilization management includes:

• Prior Authorization
• Predeterminations
• Post-Service Reviews

What is Prior Authorization

Prior authorizations are a pre-service medical necessity review. A prior authorization is the process where we review the requested service or drug to see if it is medically necessary and covered under the member’s health plan. Not all services and drugs need prior authorization. A prior authorization is not a guarantee of benefits or payment. The terms of the member’s plan control the available benefits.

Who Requests Prior Authorization

Usually, the provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. Sometimes, a plan may require the member request prior authorization for services. Information for members is on our member site.

Most out-of-network services require utilization management review. If the provider or member does not get prior authorization for out-of-network services, the claim may be denied. Emergency services are an exception.

Why Obtain a Prior Authorization

If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists:

• The service or drug may not be covered and the ordering or servicing provider will be responsible.
• We may conduct a post-service utilization management review, which may include requesting medical records and review of claims for consistency with:
  • Medical policies
  • State and federal requirements
  • Member’s benefits
  • Other clinical guidelines

How to Submit a Prior Authorization

Prior authorization may be required via BCBSTX's medical management, eviCore^® healthcare, AIM specialty Health^® or Magellan Healthcare^®. You can review how to submit each request as well as statistical data here.

What is a Predetermination of Benefits

A predetermination of benefits is a written request for verification of benefits before rendering services. Learn more about Predetermination of Benefits Requests.

Eligibility and Benefits Reminder

Health care providers must obtain eligibility and benefits through Availity^® or a preferred vendor first to confirm membership, check coverage, determine if you are in-network for the member/participant's policy, determine whether prior authorization is required and where to submit the request. Availity^® allows prior authorization determination by procedure code and providers can submit requests on Availity using the Authorization & Referral tool. Learn more about Eligibility and Benefits and Availity.

What is Post-Service Utilization Management Review

A post-service utilization management review occurs after the service occurs. During a post-service utilization management review, we review clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan. We may ask you for the information we do not have.

We may also conduct a post-service utilization management review if you do not obtain a required prior authorization before the services were rendered. If the service required a prior authorization for a Medicare or Medicaid member, the claim will be denied with no post-service review

Prior Authorization Lists

Refer to the following for services and/or procedure codes that may require prior authorization:

• Behavioral Health Services
• Prior Authorization Lists for Fully Insured and Administrative Services Only (ASO) Plans
• Prior Authorization Lists for Blue Cross Medicare Advantage (PPO)^SM and Blue Cross Medicare Advantage (HMO)^SM
• Prior Authorization Lists for Designated Groups
  • Employee Retirement Groups of Texas (ERS)

eviCore is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.

AIM Specialty Health (AIM) is an operating subsidiary of Anthem and an independent medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to Blue Cross and Blue Shield of Texas.

BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore or AIM. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.