Blue Choice PPO^SM Changes to Preauthorization Services Including New Health Advocacy Solutions (HAS) Service Options Effective Jan. 1, 2018

Effective January 1, 2018, Blue Cross and Blue Shield of Texas (BCBSTX) will be changing the preauthorization requirements for Blue Choice PPO members including 3 new Health Advocacy Solutions (HAS) service options (Primary, Advanced, or Premier) that are available to be selected for Blue Choice PPO self-funded groups. Also, Blue Choice PPO fully insured members will have additional care categories that will require preauthorization through BCBSTX.

The following is a summary of the changes:

As a reminder, it is always important to check eligibility through Availity^TM or your preferred web vendor prior to rendering services. In addition, this step will help you determine if your services require preauthorization through BCBSTX or eviCore.

For Blue Choice PPO, self-funded groups who have selected the Premier HAS service option, the preauthorization list should be reviewed for the following care categories to determine if authorization is required through BCBSTX:

• Cardiology
• Ear, nose and throat (ENT)
• Gastroenterology
• Musculoskeletal (MSK)
• Neurology
• Non emergent Air Ambulance
• Outpatient surgery
  • Orthognathic Surgery
  • Mastopexy
  • Reduction Mammaplasty
  • Bunionectomy
  • Carpal Tunnel Repair
  • Cardiac Catheterization
  • Inguinal Hernia Repair
  • Lithotripsy
• Specialty pharmacy (medical benefit specialty drugs)
• Wound Care
• Dialysis (prenotification)
• Maternity and delivery (prenotification)

For Blue Choice PPO self-funded groups who have one of the three HAS service options (Primary, Advanced, or Premier), preauthorization should be reviewed for the following specialized care categories to determine if authorization is required through eviCore, an independent company that provides specialty medical benefits management on behalf of BCBSTX:

• Radiation therapy (Primary, Advanced and Premier)
• Molecular and genomic testing (Primary, Advanced and Premier)
• Advanced radiology imaging services* (Advanced and Premier)
• Sleep studies/Durable Medical Equipment (DME) (Advanced and Premier)

*Note – For HAS Primary members, providers should submit a "notification" to eviCore for advanced radiology services. Preauthorization is not required.

For Blue Choice PPO self-funded groups who have not selected a HAS service option, there are no changes to the preauthorization list.

For Blue Choice PPO fully insured members, preauthorization should be reviewed for the following care categories to determine if authorization is required through BCBSTX:

• Cardiology
• Ear, nose and throat (ENT)
• Gastroenterology
• Musculoskeletal (MSK)
• Neurology
• Non emergent Air Ambulance
• Outpatient surgery
  • Orthognathic Surgery
  • Mastopexy
  • Reduction Mammaplasty
• Sleep Studies
• Wound Care

To obtain preauthorization for the services that require authorization through BCBSTX:

• Continue to use iExchange^®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSTX.
• For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website.

To obtain preauthorization for certain care categories which are handled through eviCore:

• Authorization can be obtained by accessing www.evicore.com or calling 855-252-1117.
• eviCore will be hosting education sessions December 5th, 6th and 7th, 2017. During these training sessions, BCBSTX will also provide a brief overview of the new Health Advocacy Solutions (HAS) benefit and Availity^TM roles. Anyone wishing to attend one of the sessions must register in advance. Sessions are free of charge and will last approximately one hour. You may register on the http://evicore.webex.com website under Training Center. Find the orientation sessions named "Blue Cross and Blue Shield of Texas Provider Program Name Orientation Session" and select by Program Name (Radiation Therapy, Genomic Lab, Radiology, Sleep Testing or Sleep DME).

The following Blue Choice PPO Preauthorization/Referral Requirements Lists, may be found under Clinical Resources on the provider website:

• Blue Choice PPO Fully-Insured Members
• Blue Choice Self-Insured Groups HAS Primary
• Blue Choice Self-Insured Groups HAS Advanced
• Blue Choice Self-Insured Groups HAS Primary
• Blue Choice PPO Self-Funded Groups Who Have Not Selected HAS

For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section of our provider website.

Services performed without benefit preauthorization may be denied in whole or in part for payment and you may not seek any reimbursement from the member. For any service not approved for payment, BCBSTX will provide all appropriate appeal rights for review. Please note that a member penalty may also apply based on the benefit plan.

Refer to the BCBSTX provider website or for additional information including provider training information. If you have any questions, please contact your Network Management Representative.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized 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.

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.