Certain services require preauthorization before they can be covered by your health insurance plan.
Responsibility for Requesting Preauthorization
For In-Network ProvidersIn-network providers or specialists will request preauthorization for you. You may want to check with your health care provider to make sure that the preauthorization was obtained before you have the service or procedure.
For Out-of-Network or Out-of-State ProvidersYou are responsible for ensuring that out-of-network and out-of-state providers have received preauthorization before the service is performed.
If your provider does not submit a preauthorization for the services listed, the claims for those services may be denied and may be considered your liability.
What types of procedures require preauthorization?
Whether preauthorization is required may depend on your benefit plan. Some services that need preauthorization can include:
- Computed Tomography (CT/ CTA)
- Magnetic Resonance Imaging (MRI/MRA)
- Nuclear Cardiology
- Positron Emission Tomography (PET)
- Surgical procedures
- Durable medical equipment
- Pain management
Note: Standard X-rays and radiology services performed with emergency room services and inpatient hospitalization are not included in this requirement.
If a service is not preauthorized or the preauthorization is denied, the claim may be denied and you may be responsible for the payment of the charges.
Please be aware that at times, we may deem the service as not medically necessary, and the preauthorization will be denied. If the service is provided, but not approved, you may be responsible for the charges associated with the service. Below is the preauthorization code list which is subject to change.
Preauthorization Code List
Why are preauthorization necessary?This ensures that:- Your benefit plan covers the service
- The service is medically necessary
- The service is performed in the right health care setting
- Special medical circumstances are identified that require review and follow-up
If a preauthorization is required, ask your provider to submit a preauthorization to Blue Cross and Blue Shield of Nebraska.
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