eviCore Prior Authorization Program

Blue Cross and Blue Shield of Texas (BCBSTX) has contracted with eviCore healthcare (eviCore)* to provide certain utilization management prior authorization services for our government programs. eviCore is an independent company that provides specialty medical benefits management for BCBSTX. Services requiring prior authorization through eviCore are outlined below.

Prior Authorization

To determine which services require prior authorization (for medical necessity)** through eviCore for BCBSTX government members, refer to:

• Medicare Advantage members
  

  Prior Authorizations Lists for Blue Cross Medicare Advantage (PPO)^SM and Blue Cross Medicare Advantage (HMO)^SM

• Medicaid members
  

  Clinical Resources page on the BCBSTX Medicaid website

Check Member Eligibility and Benefits

Use the Availity^® Provider Portal  or your preferred vendor to check eligibility and benefits before rendering services. This step will also help you determine if your services require prior authorization through BCBSTX or eviCore.

CPT Codes and More Information

For more detailed information, including specific CPT codes that require eviCore prior authorization, visit the eviCore implementation site  and select the BCBSTX health plan for the applicable CPT/HCPCS code lists and physician worksheets by service.

eviCore Contact Information

Obtain prior authorizations through eviCore using one of the following methods:

• The eviCore Healthcare Web Portal  is 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.
• Providers can call toll-free at 1-855-252-1117 between 6 a.m. to 6 p.m. (central time) Monday through Friday and 9 a.m. - noon Saturday, Sunday and legal holidays.

Available Trainings

Visit the eviCore implementation site  or the BCBSTX Educational Webinar/Workshop Sessions section of the Provider Training website for upcoming trainings.

* 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. ** Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization 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 Prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.