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Update to Prior Authorization Codes for Medicare and Medicaid Members

April 30, 2021

What’s Changing: Blue Cross and Blue Shield of Texas (BCBSTX) is changing prior authorization requirements for Medicare and Medicaid members to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association (AMA). A summary of changes is included below.

For Medicare: Refer to Prior Authorization Lists on the Utilization Management section of our provider website. The revised lists can be found on the Prior Authorization Lists for Blue Cross Medicare Advantage (PPO)^SM and Blue Cross Medicare Advantage (HMO)^SM page.

For Medicaid: Refer to Prior Authorization Lists and Reports on the Utilization Management section of our Medicaid provider website.

Changes include:

July 1, 2021 - Removal of Advanced Imaging codes previously reviewed by eviCore
July 1, 2021 - Removal of Genetic Testing codes previously reviewed by eviCore
July 1, 2021 - Adding Genetic Testing codes to be reviewed by eviCore
July 1, 2021 - Adding Specialty Drug codes to be reviewed by eviCore

Check Eligibility and Benefits: To identify if a service requires prior authorization for our members, check eligibility and benefits through Availity^® or your preferred vendor.

Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

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 BCBSTX.

eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSTX.

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.