If your providers are not on the network, you are responsible for obtaining prior authorization. If you don`t, we may not cover the costs. To make sure your provider is on the network, see Provider Finder®. Prior approval may be required by the medical management of BCBSTX, eviCore® healthcare, AIM specialty Health® or Magellan Healthcare®. Here you can check how to submit each application as well as statistical data. It then completes the pre-approval and sends the results to the provider. If you have any questions about the answer, contact BCBSTX Medical Management or the authoritative provider. If you do not obtain pre-approval through the pre-approval process for services and drugs on our pre-approval lists: Pre-approval or rejection statistics from the previous calendar year for fully insured members are available for review: Typically, your health care providers take care of the pre-approval before providing a service. However, it`s always a good idea to check if your suppliers have the necessary approval. It is important that providers use Availability® or your preferred provider to verify eligibility and benefits, determine if you are on the network for your patient, and whether prior approval or pre-registration is required. With availability, you can use the procedure code to determine whether pre-approval is required. For more information about availability, see « Eligibility and Benefits » on the provider`s website.
Use the search below to find out if you need pre-approval or not. Your procedure can fall into one of the 3 categories listed below. Check with us to see if your provider has requested prior authorization before using the services. Typically, the provider is responsible for requesting prior authorization before performing a service if the member sees a provider in the network. Sometimes a plan may require the member to apply for prior authorization for services. Information for members can be found on our members page. Significant changes have been made to pre-approval requirements for members with Blue Choice PPOSM, Blue EssentialsSM, Blue Advantage HMOSM and Blue PremierSM. In addition, we are implementing our new MyBlue Health targeted network as of January 1, 2020. The pre-approval requirements for MyBlue Health are the same as our HMO Blue Advantage plan. Sometimes you may need to get approval from Blue Cross and Blue Shield of Texas (BCBSTX) before we cover certain inpatient, outpatient and home health services, as well as prescription medications. This is called pre-approval, pre-authorization or pre-approval. These terms all refer to the requirements you may need to complete before treatment can begin.
What`s New: Blue Cross and Blue Shield of Texas (BCBSTX) will update their lists of process codes that require prior approval for certain business members to reflect codes that are new, replaced, or removed due to usage management or American Medical Association (AMA) updates. To view Blue Plan medical policies outside the region or general information on pre-certification or pre-authorization, please select the type of information requested, enter the first three characters of the member`s identification number on the Blue Cross Blue Shield ID card and click « GO ». If your doctor has not asked for prior authorization, you can request it. Call the number on your BCBSTX membership card and our customer service will help you get started. Verify eligibility and benefits: To determine if a service requires prior approval for our members, check eligibility and benefits through Availity® or your preferred provider. Renewal of an existing pre-approval may be requested up to 60 days prior to the expiration of existing BCBSTX contracts with third-party providers, including AIM Specialty Health® (AIM), eviCore® healthcare and Magellan Healthcare, for certain pre-approval services. Most off-grid services require a usage management review. If the provider or member does not receive prior approval for services outside the network, the claim may be denied. Emergency services are an exception. We may also conduct a post-service usage management review if you do not obtain the required prior approval before providing the Services. If the service required prior approval for a Medicare or Medicaid member, the claim will be denied without verification under the service *Code E1399 may require prior approval from BCBSTX medical management, depending on the description of the unlisted EMR.
If you want to view health data statistics for pre-approval, click the appropriate button to search below. For best results, use Google Chrome. Health care providers must first obtain eligibility and benefits through® Availability or a preferred provider to confirm membership, verify coverage, determine if you are on the network for the member/participant`s policy, determine if prior approval is required and where to submit the application. Availability® allows you to determine pre-approval by process code, and vendors can submit availability requests using the Authorization and Reference tool. Learn more about eligibility, benefits and availability. What`s New: On January 1, 2021, Blue Cross and Blue Shield of Texas (BCBSTX) will update their list of CPT® codes (current procedural terminology) that require prior approval to reflect changes due to new, replaced, or deleted codes implemented by the American Medical Association (AMA) and BCBSTX usage management updates. You or your supplier can request an extension of a pre-approval up to 60 days before expiration. To see the full list of the history of all previous authorization data, click below to download a copy. You can view data from the last 3 years. Important Update to the HealthSelect of Texas® Pre-Authorization Procedure Code: Effective September 1, 2021, the following procedural codes will be removed from the list of services requiring prior approval. Payment may be declined if you perform procedures without authorization.
In this case, you will not be able to bill your patients. Services requiring prior approval from BCBSTX Medical Management As a reminder, it is important to verify eligibility and services before providing services. This step will help you determine if prior approval is required for a member. For more information, such as definitions and links to useful resources, see the Permissions and Benefits section of the BCBSTX provider website. For more information: A revised list of codes published on 1. Starting in January 2021, you will find the « Pre-Approval » section of our supplier website. For more information on CPT code updates, visit WADA`s website. We may also conduct a post-service usage management review if you or your provider do not obtain the required prior authorization before receiving the services. The procedures or services listed below may require prior approval or notification from BCBSTX Medical Management or another named supplier for specific named groups. *To see if you are fully insured, check your membership card. « TDI » will be printed on your card when you are fully insured.
If « TDI » is not printed, check your performance brochure to see your list of services that require prior approval. If you have any questions, please call the customer service number on your BCBSTX membership card and view details of the number of pre-submitted, approved and denied approvals. To see the full list of services and medications that require pre-approval, click below to download a copy of the table. Unless otherwise specified, these pre-approval requirements will apply from 1 January 2022. Get pre-approval/pre-notification as follows: The following describes the process that suppliers perform to submit requests for prior authorizations or pre-notifications. Pre-approvals are a review of medical necessity prior to service. Pre-approval is the process by which we review the requested service or medication to determine if it is medically necessary and covered by the member`s health insurance plan. .