05/14/2024

What Changed: Blue Cross and Blue Shield of Texas changed prior authorization requirements for Medicaid members due to updates from our Utilization Management prior authorization assessment. We no longer use eviCore as of April 30, 2024.

Effected May 1, 2024, all categories previously reviewed by eviCore for prior authorization are now processed through BCBSTX:

• Specialty Pharmacy 
•  Musculoskeletal care categories:
  • Physical Therapy
  • Occupational Therapy 

Save time!

Refer to our Prior Authorization Lists and Reports (located bottom of page) on the Utilization Management section of our Medicaid provider website.

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

Contact BCBSTX Utilization:

• STAR and CHIP Phone: 1-877-560-8055 / Fax: 1-855-653-8129
• STAR Kids Phone: 1-877-784-6802 / Fax: 1-866-644-5456
• Behavioral Health Fax: 1-888-530-9809

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, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.