Prior Authorization (Commercial Lists)

The procedures and services on the lists below may require prior authorization or prenotification. They may or may not be covered under the member’s benefit plan. To be sure, always check eligibility and benefits through Availity® Essentials or your preferred vendor. You can also check the member benefit booklet or call the number on the member ID card.

We may conduct medical necessity reviews on services that don’t require prior authorization.

We will periodically update the lists to comply with American Medical Association and Centers for Medicare & Medicaid Services guidelines and procedure code updates or our medical policies and clinical guidelines. 

Commercial Services and Code Lists

The services lists offer a summary of care categories and services that may require prior authorization as well as the criteria for determining medical necessity.

To identify fully insured members, look for the TDI on their member ID card.

The following lists expired on Dec. 31, 2024

Digital Lookup Tool for Fully Insured Members

Select the appropriate category below to find out if a member’s procedure may require prior authorization:

Related Links

 

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. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.

MCG Care Guidelines are administered and provided by MCG Health, an independent company that has contracted with BCBSTX to provide care and disease management for members with coverage through BCBSTX.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or received a recommended clinical review is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.