Utilization Management

Utilization management is at the heart of how you access the right care, at the right place and at the right time. It includes:

• Prior Authorization
• Predeterminations
• Post-service reviews

We use evidence-based clinical standards of care to make sure you get the health care you need.

What Is Prior Authorization?

Sometimes you may need to get approval from Blue Cross and Blue Shield of Texas (BCBSTX) before we will cover certain inpatient, outpatient and home health care services and prescription drugs. This is called prior authorization, preauthorization or prior approval. These terms all refer to the requirements that you may need to meet before treatment may begin.

Who Requests Prior Authorization?

Usually, your health care providers will take care of prior authorization before they perform a service. But, it's always a good idea to check if your providers have the needed approval.

If your providers aren't in network, you'll be responsible for getting the prior authorization. If you don't, we may not cover the cost. To make sure your provider is in network, check Provider Finder^®.

You or your provider can request a renewal of a prior authorization up to 60 days before it expires.

BCBSTX contracts with outside vendors, including AIM Specialty Health^® (AIM), eviCore^® healthcare and Magellan Healthcare for certain prior authorization services.

How You Can Request Prior Authorization

Check with us to see if your provider has requested prior authorization before you get any services.

If your health care provider has not requested prior authorization, you can request it. Call the number on your BCBSTX member ID card. Our Customer Service will help you begin the process.

What Happens During the Prior Authorization Process?

BCBSTX reviews the requested service or drug to see if it's medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

We need the following information to complete a prior authorization request:

• Your name, subscriber ID number and date of birth
• Your provider's name, address and National Provider Identifier (NPI)
• Information about your medical or behavioral health condition
• The proposed treatment plan, including any diagnostic or procedure codes (your provider can help you with these)
• The date you'll receive service and the estimated length of stay (if you are being admitted)
• The place you're being treated

What Is Predetermination?

Predeterminations are:

• Voluntary utilization management reviews
• Not necessary for services and drugs on the prior authorization list
• May be used if you are not sure about coverage or whether we may not consider it medically necessary
• Written requests for verification of benefits before getting services

If you have additional questions, please contact the Customer Service number on your member ID card.

What Is Post-Service Utilization Management Review?

A post-service utilization management review happens after you receive a service. During this review, we check whether a service or drug was medically necessary and covered under your health plan. We may ask your provider for more information.

We may also conduct a post-service utilization management review if you or your provider does not get a required prior authorization before you receive services.

^*To see if you are fully insured, check your member ID card. "TDI" will be printed on your card if you are fully insured. If you do not see "TDI" printed, check your benefit booklet to see your list of services that require prior authorization. If you still have questions, please call the Customer Service number on your BCBSTX member ID card.