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.
- Prior Authorization Services List for Fully Insured and Certain ASO Groups Effective Jan. 1, 2025 (Updated March 1, 2025)
- Prior Authorization Procedure Codes List for Fully Insured Plans and Certain ASO Groups Effective Jan. 1, 2025 (Updated March 1, 2025)
- Prior Authorization Services List for Other ASO Groups Effective Jan. 1, 2025
- Prior Authorization Procedure Codes List for Other ASO Plans Effective Jan. 1, 2025
The following lists expired on Dec. 31, 2024
- Prior Authorization Services List for Fully Insured and Certain ASO Groups Effective Jan. 1, 2024 − Dec. 31, 2024
- Prior Authorization Procedure Codes List for Fully Insured Plans and Certain ASO Groups Effective Jan. 1, 2024 − Dec. 31, 2024 (Includes changes effective Oct. 1, 2024)
- Prior Authorization Services List for Other ASO Groups Effective Jan. 1, 2024 - Dec. 31, 2024
- Prior Authorization Procedure Codes List for Other ASO Plans Effective Jan. 1, 2024 - Dec. 31, 2024 (Includes changes effective 10/01/2024)
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 Authorization & Referrals
- Blue ApprovRSM
- MCGTM Care Guidelines: Providers can access the guidelines in Availity’s Payer Spaces for Blue Cross and Blue Shield of Texas under the Resources tab
- Medical Policies
- Prior Authorization Exemptions
- Recommended Clinical Review