01/16/2025
We’re changing prior authorization requirements for members of Medicare Advantage to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association. A summary of changes is included below.
Medicare: Refer to Prior Authorization Lists on the Utilization Management section of our provider website. The revised lists can be found on the Prior Authorization Lists for Blue Cross Medicare Advantage (PPO)SM and Blue Cross Medicare Advantage (HMO)SM page.
Changes effective April 1, 2025 include:
- Addition of Specialty Drug codes to be reviewed by eviCore
- Addition of Lab Management codes to be reviewed by eviCore
- Removal of Lab Management codes previously reviewed by eviCore
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.
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.
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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 is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.
BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.