Update to Prior Authorization Codes For Commercial Members

What’s New: Blue Cross and Blue Shield of Texas (BCBSTX) will be updating its lists of procedure codes requiring prior authorization, for some commercial members, to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association (AMA).

More Information: Refer to Prior Authorization Lists on the Utilization Management section of our provider website, Revised lists can be found on the Prior Authorization Lists for Fully Insured and Administrative Services Only (ASO) Plans. Changes include:

Effective April 16, 2021

• Removed review by AIM for E1399* - Sleep Medicine Durable Medical Equipment review by AIM

*Code E1399 may require prior authorization by BCBSTX medical management dependent on the description of the unlisted DME.

Effective July 1, 2021

• Added review by BCBSTX Medical Management for E0764 - Functional Neuromuscular Stimulator
• Removed review by AIM for:
  • 76975 from Advanced Imaging
  • G9840 and G9841 from Molecular Genetic Testing
  • 62324 and 64640 from Pain Management

Check Eligibility and Benefits: To identify if a service requires prior authorization for our members, check eligibility and benefits through Availity^®  or your preferred vendor.

Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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.

AIM Specialty Health (AIM) is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX.

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.