Does BCBS of Texas require prior authorization?

As a PPO/POS, HMO or Traditional contracted provider with Blue Cross and Blue Shield of Texas, you are responsible for the completion of the prior authorization process for BlueCard members.

How to Determine Requirements:

Telephone: Call the BlueCard Eligibility line at 1-800-676-2583 and ask to be transferred to the Medical Management Department.

Electronic: Use the Pre-Cert/Pre-auth Router (out-of-area members) to view the applicable Blue Plan's medical policy or general pre-certification/prior authorization information. If pre-certification/prior authorization is required, submit an electronic request (278 transaction) through Availity® or your preferred web vendor portal.

Note:

Contact the Plan that issued the prior authorization with updated or clinical information as necessary if there is a change in the patient status from the original prior authorization.

The prior authorization must cover the entire date span and all services submitted on the claim to avoid requests for additional information and possible delays or denials.

Failure to prior authorize may result in reduced payment or denial and health care providers cannot collect these fees from the members. Out-of-network services require prior authorization.

Group Specific Information

Outpatient Advanced Diagnostic Imaging Services for HMA Members Require Authorization —

• To obtain authorization for outpatient advanced diagnostic imaging services for HMA (prefix HHM) members call 1-888-376-6544

Medicare Advantage Product Update: Identifying Michigan Public School Employees Retirement System Members

• Remember prior authorization is required for Michigan Public School Employees Retirement System (MPSERS) — Prefix XYO members for:
  • Acute care admissions
  • Skilled nursing admissions
  • Inpatient rehabilitation admissions
  • Radiology services

Imaging Program for The Boeing Company Members

• The Boeing Company, in partnership with American Imaging Management® (AIM®), implemented a Radiology Quality Initiative (RQI) program for all of its members. RQI is a prospective clinical review program for outpatient advanced diagnostic imaging services. Participating members can be identified by the three-character prefixes ('BHP', 'BYR', 'BEM', 'BCU') that appear on their member ID cards. The diagnostic imaging studies covered under this program include the following:
  • Computed Tomography (CT/ CTA)
  • Magnetic Resonance Imaging (MRI/MRA)
  • Nuclear Cardiology
  • Positron Emission Tomography (PET)

AIM Specialty Health is an independent medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas (BCBSTX).

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or AIM Specialty Health

Doctors and Hospital

When picking a doctor, you do not need an authorization for an in-network doctor. If you want to see a Medicaid doctor out of network, work with your service coordinator so arrangements are made to get authorizations for your out-of-network provider. To learn more about how to select a primary care provider (PCP), please refer to the STAR Kids Member Handbook.

Do you need help getting to a medical appointment? See transportation services.

You can also contact your service coordinator with any questions or concerns.

• Your right to protect your needs, and understand the information and care you receive
• Your responsibility to give your providers the information they need to take care of you
• How to file a complaint
• How to report health care fraud

If you have questions, please call Service Coordination toll-free at 1-877-301-4394.

Prior Authorization and Referrals

Prior authorizations are not needed for in-network PCPs or other providers. Your child's PCP may send you to a different provider, including a specialist, for special care or treatment. A referral to an in-network specialist is not needed. Blue Cross and Blue Shield of Texas (BCBSTX) will allow members to see out-of-network Medicaid specialists for medically necessary services.

OB/GYN Providers

BCBSTX also allows members to see out- of-network OB/GYN providers for medically necessary services. You should notify a service coordinator if you are going to see an out of network OB/GYN to ensure that the provider is loaded in our system so that they can file claims.

Behavioral Health and Substance Abuse Treatment Services

You do not need a referral for behavioral health or substance abuse treatment services to see a Magellan network provider. BCBSTX STAR Kids members get behavioral health/substance abuse services through Magellan Health Services. If you want to see an out-of-network provider, you need to get a prior authorization for to ensure Magellan has the provider information needed to accurately pay claims. A Magellan Health Care Coordinator will work with your child’s service coordinator to ensure your child has access to the behavioral health services needed. You can also call Magellan at 1-800-424-0324.

Emergency Care and Urgent Care

Emergency or urgent care does not require authorization. You do not need an OK from us or need a referral from your PCP to see a family planning care provider. You can contact your child's service coordinator for help scheduling an appointment at 1-877-301-4394 or call the Customer Advocate Department at 1-877-688-1811.

Applied Behavioral Analysis for Children with Autism Spectrum Disorder

Applied Behavioral Analysis (ABA) therapy is now a benefit for STAR Kids members as a covered benefit through Texas Medicaid. ABA can help children with Autism Spectrum Disorder (ASD) develop improved function with their peers and caregivers. To qualify for ABA, your child must first have special testing to confirm their diagnosis of ASD. 

ABA testing is more thorough than what most pediatricians can do as part of their practice. The testing must be performed by a specialist such as a developmental pediatrician, a neurologist, a psychiatrist, a licensed psychologist, or an Autism diagnosis team. Speak to your child’s pediatrician about getting a referral to one of these specialists.

Please see the ABA therapy Frequently Asked Questions for more information.

Go to Provider Finder® to search for and print a list of ABA providers in your area.

If you have more questions about ABA services, please call BCBSTX STAR Kids Service Coordination toll-free at 1-877-301-4394. Members with hearing or speech loss can call the TTY line at 711.

Does Bcbstx require prior authorization?

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