June 2017
eviCoreTM Current and Expanded Preauthorization Requirements
Back in October 2016, Blue Cross and Blue Shield of Texas (BCBSTX) contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to begin providing preauthorization requirements for certain specialized services for Blue Advantage HMOSM. Over the coming months, additional BCBSTX products and services are being added as indicated below.
The following is a summary of the pre-service authorizations for specialized clinical services that eviCore will manage. Be sure to closely review the effective dates and services included for each individual product as they do vary.
Blue Cross Medicare Advantage (HMO)SM and Blue Cross Medicare Advantage (PPO)SM
Effective June 1, 2017:
- Outpatient Molecular Genetic
- Outpatient Radiation Therapy
- Musculoskeletal
- Chiropractic
- Physical and Occupational Therapy
- Speech Therapy
- Spine Surgery (Outpatient/Inpatient)
- Spine Lumbar Fusion (Outpatient/Inpatient)
- Interventional Pain
- Outpatient Cardiology & Radiology
- Abdomen Imaging
- Cardiac
- Imaging
- Chest Imaging
- Head Imaging
- Musculoskeletal
- Neck Imaging
- Obstetrical Ultrasound Imaging
- Oncology Imaging
- Pelvis Imaging
- Peripheral Nerve Disorders (Pnd) Imaging
- Peripheral Vascular Disease (Pvd) Imaging
- Spine Imaging
- Outpatient Medical Oncology
- Outpatient Sleep
- Outpatient Specialty Drug
Blue Choice PPOSM and Blue PremierSM Fully Insured Members* (identified by TDI listed on their membership card)
Effective Aug. 1, 2017:
- Molecular and genomic testing
- Radiation oncology for all outpatient and office services
*Currently, the eviCore preauthorization requirement does not include Administrative Services Only (ASO) Blue Choice PPO or Blue Premier members.
Blue EssentialsSM and Blue Essentials AccessSM Fully Insured Members* (identified by TDI listed on their membership card)
Effective Sept. 1, 2017:
- Molecular and genomic testing
- Radiation oncology for all outpatient and office services
- Advanced radiology imaging
- Sleep studies and sleep durable medical equipment
*Currently, the eviCore preauthorization requirement does not include Administrative Services Only (ASO) Blue Essentials or Blue Essentials Access members.
Employee Retirement System of Texas (ERS): HealthSelect of Texas and Consumer Directed HealthSelect
Effective Sept. 1, 2017:
- Molecular and genomic testing
- Radiation oncology for all outpatient and office services
- Advanced radiology imaging
- Sleep studies and sleep durable medical equipment
Blue Advantage HMO and Blue Advantage PlusSM HMO
Effective Oct. 3, 2016:
- Outpatient Molecular Genetics
- Outpatient Radiation Therapy
The updated Preauthorization/Referral/Notification Requirements Lists and the Prior Authorization and Referral List for ERS can be found on the Clinical Resources page of BCBSTX’s provider website. These lists include the services that require preauthorization or prior authorization through eviCore for the effective dates listed above.
For a detailed list of the services that require authorization through eviCore, refer to the eviCore implementation site. Services performed without authorization may be denied for payment and you may not seek reimbursement from members/subscribers.
Preauthorization or ERS prior authorization through eviCore can be obtained using one of the following methods:
- Use the eviCore healthcare web portal, which is available 24/7. After a one-time registration, you can initiate a case, check status, review guidelines, view authorizations and eligibility, and more. The web portal is the quickest, most efficient way to obtain information.
- Call eviCore at 855-252-1117 toll-free between 6 a.m. - 6 p.m. CT, Monday through Friday, and 9 a.m. - noon CT, Saturday, Sunday and legal holidays.
For all other services that require a referral and/or authorization as noted on the Preauthorization/Referral Requirements Lists or the Prior Authorization/Referral List for ERS, continue to use iExchange®. iExchange is accessible to physicians, professional providers and facilities contracted with BCBSTX. Learn more about iExchange or set up a new account on BCBSTX’s provider website.
Watch for additional information and training opportunities for eviCore in future editions of this newsletter, on the BCBSTX provider website or on the eviCore implementation site.
If you have any questions, please contact your BCBSTX Network Management Representative.
As a reminder, it is important to check eligibility and benefits prior to rendering services. This step will help you determine if a member requires benefit preauthorization or prior authorization. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSTX’s provider website.
Checking eligibility, benefit information and/or if a service has been preauthorized or prior authorized 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 any questions, please call the number on the back of 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.
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.