May 2017
Changes to the New Preauthorization Requirements through eviCoreTM Effective June 1, 2017
Blue Cross and Blue Shield of Texas (BCBSTX) previously notified providers that it has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company to provide Utilization Management services for new preauthorization requirements outlined below for the Blue Cross Medicare Advantage (HMO)SM and Blue Cross Medicare Advantage (PPO)SM provider networks.
A correction was made to the preauthorization list, which will be effective June 1, 2017, regarding codes E0748 and 22614. Preauthorization of codes E0748 and 22614 will be handled by eviCore, instead of BCBSTX.
In addition, the Cardiac Rhythm Implantable Device (CRID) implementation has been delayed and will not be part of the eviCore preauthorization program on June 1, 2017. Please look for updates regarding the CRID implementation in the near future.
Effective June 1, 2017, eviCore will manage preauthorization for the following specialized clinical services:
- Outpatient Molecular Genetics
- 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
- Cardiac Rhythm Implantable Device (Crid)
- 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
The Blue Cross Medicare Advantage (HMO) Preauthorization Requirements List and Blue Cross Medicare Advantage (PPO) Preauthorization Requirements List have been updated to include the services listed above that require preauthorization through eviCore, for dates of service beginning June 1, 2017.
For a detailed list of CPT® codes that apply to the above services, please go to Specialty UM Pre-Authorization Program Code Listing. The updated preauthorization lists will be located on the applicable Blue Cross Medicare Advantage (HMO) Network Participation and Blue Cross Medicare Advantage (PPO) Network Participation website pages.
To obtain preauthorization through eviCore you may use one of the following methods:
- The eviCore HealthCare Web Portal will be available 24x7. After a one-time registration, you can initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
- Texas providers can call toll-free at 855-252-1117 between 6 a.m. to 6 p.m. (CT) Monday through Friday, and 9 a.m. to noon on Saturdays, Sundays and legal holidays.
BCBSTX and eviCore will be providing additional information, including eviCore website and training opportunities in the future, on the BCBSTX provider website and in this newsletter.
Services performed without preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek reimbursement from the member.
For all other services (not listed above), that require a referral and/or preauthorization, providers will continue to use the current telephone and fax numbers as noted on the preauthorization/referral requirements list, including those for iExchange® and AvailityTM. iExchange is accessible to physicians, professional providers and facilities contracted with BCBSTX. Go to iExchange to learn more or set up a new account.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.
Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.
eviCore is a trademark of eviCore healthcare, 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, 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. Aerial, iExchange and Medecision® are trademarks 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 Availity or Medecision. 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.