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

The procedures or services on the below lists may require prior authorization or prenotification by BCBSTX Medical Management, eviCore Healthcare^® or Magellan Healthcare^®.

• These lists are not exhaustive.
• The presence of codes on these lists does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits.
• Consult Availity^® or your preferred vendor for eligibility and benefits, the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.

Blue Cross Medicare Advantage Prior Authorization Requirement List

• Effective 01/01/2022
• Effective 01/01/2021 – 12/31/2021

Blue Cross Medicare Advantage Procedure Code List

• Effective 01/01/2022
• Effective 01/01/2021 - 12/31/2021

Blue Cross Medicare Advantage Procedure Code List Change Summary

• Effective 01/01/2022
• Effective 01/01/2021 -12/31/2021

eviCore is an independent specialty medical benefits management company that provides utilization management services for Blue Cross and Blue Shield of Texas.

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 Blue Cross and Blue Shield of Texas.

BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore or AIM. 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.

Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.