Dec. 30, 2021
What’s Changing: Blue Cross and Blue Shield of Texas (BCBSTX) is changing prior authorization requirements for Blue Cross Medicare Advantage members to reflect new, replaced or removed procedure codes due to updates from Utilization Management or the American Medical Association (AMA). A summary of changes is included below.
Changes effective April 1, 2022 include:
- Addition of Lab codes to be reviewed by eviCore healthcare (eviCore)
- Addition of Specialty Drug codes to be reviewed by eviCore
- Addition of Medical Oncology codes to be reviewed by BCBSTX
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.
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.
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.
The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.