Some medical services and medications may need a prior authorization (PA), sometimes called a “pre-authorization” or an “OK,” before care or medication can be covered as a benefit. Ask your provider to go to Prior Authorization Requests to get forms and information on services that may need approval before they prescribe a specific medicine, medical device or procedure.
How It Works
If the service you need requires a prior authorization, you will need to ask your PCP to get an OK from BCBSTX to make sure the service is covered. This means that both BCBSTX and your PCP (or specialist) agree ahead of time that the services or care you need are medically necessary. “Medically necessary” refers to getting care that:
- Protects life
- Keeps you from getting seriously ill or disabled
- Finds out what’s wrong or treats a disease, illness, or injury
- Helps you do things like eating, dressing, and bathing
Your PCP may send you to a different provider, including a specialist, for special care or treatment. A specialist may treat you for as long as he or she thinks you need it. If you get services from a provider that is not part of the BCBSTX CHIP network before you get the OK you need from us, we may not pay for the service.
BCBSTX allows members with special health care needs to have direct access to the right specialists for their conditions and identified needs. This includes a standing referral to a specialty doctor or having a specialist as a PCP if needed. Check with your PCP to make sure you don’t need an OK for these health services.
Some services that do not need an OK are:
- Family planning
- OB/GYN services – You must choose providers in your health plan’s network.
- Emergency care
- Texas Health Steps medical checkup appointments
- Early Childhood Intervention (ECI)
- Sexually Transmitted Infections (STI)/HIV
- Case Management for women and children
- Behavioral health and substance use services
Call the Customer Advocate Department if you have questions about services that need an OK or if you need help making an appointment with a specialist.
Need to locate a provider? Search the Provider Finder®.
How Does BCBSTX Approve a Request?
Our doctors and staff make decisions about your care based on need and benefits. They will also use tools such as medical codes, policies and clinical criteria to prescribe the most appropriate treatment. Your PCP will order any medically necessary services. BCBSTX will only pay for medically necessary covered services.