October 2017
Preauthorization and Referral Requirements Lists Are Changing Jan. 1, 2018
Beginning Jan. 1, 2018, Blue Cross and Blue Shield of Texas (BCBSTX) will be changing the preauthorization requirements for Blue Choice PPOSM, Blue EssentialsSM, Blue Essentials AccessSM, Blue PremierSM and Blue Advantage HMOSM.
The changes include three new Health Advocacy Solutions (HAS) preauthorization service options, including Primary, Advanced and Premier. These options allow Blue Choice PPO and Blue Essentials Access self-insured groups to choose one of three preauthorization-specific service options for their group. In addition, Blue Choice PPO fully insured members, Blue Essentials, Blue Essentials Access, Blue Premier and Blue Advantage HMO will have additional care categories that require preauthorization through BCBSTX or eviCore healthcareTM (eviCore).
Preauthorization for certain care categories that are handled through eviCore can be obtained by accessing evicore.com or calling 855-252-1117.
Check Eligibility First
As a reminder, it is important to check eligibility through AvailityTM or your preferred web vendor prior to rendering services. This step will help you determine if your services require preauthorization through BCBSTX or eviCore.
Please note: Services performed without benefit preauthorization may be denied in whole or in part for payment and you may not seek any reimbursement from the member. For any service not approved for payment, BCBSTX will provide all appropriate appeal rights for review. Please note that a member penalty may also apply based on the benefit plan.
Preauthorization/Referral Requirements Lists
You can find the preauthorization/referral requirements lists that are effective Jan. 1, 2018, under Clinical Resources on the BCBSTX provider website. Additional information, such as definitions and links to helpful resources, can be found in the Eligibility and Benefits section.
iExchange® Automated Preauthorization Tool
Continue using iExchange to obtain preauthorization for the services that require authorization through BCBSTX on any of the preauthorization lists. The iExchange online tool is accessible to physicians, professional providers and facilities contracted with BCBSTX. For more information or to set up a new account, refer to the BCBSTX iExchange web page.
If you have any questions or if you need additional information on the above information, please contact your Network Management Representative.
eviCore Orientation Sessions
eviCore will be hosting education sessions in December. During these training sessions, BCBSTX will provide a brief overview of the new HAS benefit and Availity’s role. Anyone wishing to attend one of the sessions must register in advance. Sessions are free of charge and will last approximately one hour.
Session |
Date |
Time |
Radiation Therapy |
Dec. 5, 2017 |
11 a.m. CT |
Genomic Lab |
Dec. 5, 2017 |
1 p.m. CT |
Radiology (CT/MR/PET) |
Dec. 6, 2017 |
1 p.m. CT |
Sleep Testing |
Dec. 7, 2017 |
10 a.m. CT |
Sleep DME |
Dec. 7, 2017 |
1 p.m. CT |
How to Register
- Choose a date and time, and then go to evicore.webex.com.
- Click on the “Training Center” tab at the top of the page.
- Find the date and time of the orientation session you wish to attend by clicking the “Upcoming” tab. All orientation sessions will be named “Blue Cross and Blue Shield of Texas Provider <Program Name> Orientation Session.”
- Click “Register.”
- Enter the registration information.
After you have registered for the conference, you will receive an email containing:
- The toll-free phone number and pass code you will need for the audio portion of the conference
- A link to the online portion of the conference
- The conference password
Please keep the registration e-mail so you will have the link and phone number for the session. If you are unable to participate in a session during any of the times listed, you can find a copy of the presentation on the eviCore BCBSTX implementation site.
Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits 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.
eviCore is a trademark of eviCore health care, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSTX.
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 any products or services offered by third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third-party vendors such as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.