We are changing prior authorization requirements for Medicaid members to reflect new, replaced, or removed codes due to updates from Utilization Management or the American Medical Association (AMA) July 1, 2022.
What’s Changing:
- Addition of one Outpatient Sleep code to be reviewed by eviCore®
- Addition of two Outpatient Specialty Drug codes to be reviewed by eviCore
- Addition of Outpatient Specialty Drug, Susvimo, reported with codes J3590 or C9399 to be reviewed by eviCore
- Addition of Outpatient Specialty Drugs, Cortophin and Vyvgart reported with codes J3490, J3590, or C9399 to be reviewed by eviCore
Refer to the Utilization Management section of our Medicaid provider website for access to the Prior Authorization Lists and Reports.
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.
CPT copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
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.
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.