Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

October 2017

Preauthorization and Referral Requirements Lists Changed Jan. 1, 2018

As of Jan. 1, 2018, Blue Cross and Blue Shield of Texas (BCBSTX) changed 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 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 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.