Blue Cross Medicare Advantage (PPO)SM and Blue …

1 1. Cardiology2. Radiology3. Medical Oncology4. Molecular Genetics5. Musculoskeletal - (PT/OT/ST;Spine/Joint/Pain/Chiro)6. Radiation Therapy7. Sleep8. Specialty DrugUtilizing the eviCore Healthcare Web Portal is the most efficient way to initiate a case, check status, review guidelines, view authorizations / eligibility and more OR Call toll-free at 855-252-1117 between 7 am -7 pm local timeMonday through Friday except ONLY between 6 am to 6 pm central time Monday through Friday and between 9 am-noon central time on Saturdays, Sundays, and legal Cross Medicare Advantage (PPO)SM andBlue Cross Medicare Advantage (HMO)SM Preauthorization List Effective 01/01/2018 Note: From 10/01/2017 through 12/31/2017 specific codes that apply can be reviewed using the BCBSTX Medicare Advantage CPT Preauthorization Code List located on under Clinical Resources blue Cross Medicare Advantage (HMO)SM and blue Cross Medicare Advantage (PPO)SM.

2 Press "CTRL" and "F" keys at the same time to bring up the search of 01/01/2018 the list can be reviewed on REQUIREMENTS* through BCBSTX - Effective 01/01/2018 Prior Authorization for Medicare Advantage PPO and HMO Medical / Surgical/Behavioral Health services listed below can be authorized by calling BCBSTX toll free 877-774-8592 between 8 to 8 (CST) Monday through Friday except specific codes that apply use BCBSTX Medicare Advantage CPT Preauthorization List located on under Clinical Resources. Network ParticipationOut of network providers must seek prior authorization for all services. The exceptions are for emergency services and services provided by RequirementsIn cases of an emergency, notification is required within one business day of admission. Medical NecessityMedical necessity must be met for all services regardless if prior authorization is required.

3 All services are subject to retrospective review and recoupment in accordance with State and Federal rules and regulations. Inpatient Facility Admission SummaryPREAUTHORIZATION REQUIREMENTS* through eviCore - Effective 01/01/2018*Including Network Exceptions for Out of Plan or Out of Network (due to Network Adequacy) for managed ServicePrior AuthorizationAllergy care, including tests and serumPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsBariatric surgeryYesBlepharoplastyYesCovered ServicePrior AuthorizationBotox InjectionsYesChemotherapy and Radiation TherapyYesDME - Medical supplies, Orthotics and Prosthesis (Any single durable medical equipment prosthetic and orthopedic device greater than $1500)Please refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization Requirements and Accumulated Annual limits without authorizationEmergency dental careYesGround - NoAir - YesHearing services and devicesYesHome health care and intravenous servicesPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsHospital services (inpatient, outpatient)Please refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization Requirements, Skilled nursing facilities in TX are reviewed through eviCore.

4 Inpatient stays with services that are managed by eviCore will be reviewed through eviCore. Hyperbaric OxygenYesInjectionsPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsImplantable DevicesYesLaboratory, X-ray, EKGs, medical imaging services, and other diagnostic testsPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsLong Term Acute Care (LTAC)Yes, (LTAC facilities in TX only are reviewed through eviCore)Minor surgeriesPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsNetwork Exceptions including Out of Plan or Out of Network (due to Network Adequacy)Please refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsNutritional counseling servicesPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsLimitations Of Covered Benefits by Member ContractAll planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse).

5 Elective admissions must have prior authorization before the admission unplanned inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse). Notification must be made within one business day of admission to the to a skilled nursing facility, a long term acute care hospital (LTACH) or a rehabilitation residential treatment program list is not exhaustive. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Contact a customer service representative to determine coverage for a specific medical service or and air ambulanceNutritional products and special medical foodsYesOffice visits to PCPs or specialists, including dieticians, nurse practitioners, and physician assistantsNoPodiatry (foot and ankle) servicesYesYesIf your child is disabled, he or she may qualify for more services.

6 Please call Customer Service and ask to speak with a Care Coordinator/Case Manager for more , MRA, MRI, and CT scansPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsRoutine physicalsNoSecond opinions (in network)NoSkilled Nursing FacilitiesYes, (SNF facilities in TX only are reviewed through eviCore)Special rehabilitation services, such as: physical therapy, occupational therapy, speech therapy, cardiac rehabilitation, pulmonary rehabilitationYes, Please refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsCovered ServicePrior AuthorizationSurgery, including pre-and post-operative care: assistant surgeon, anesthesiologist, organ transplantsPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization Requirements.

7 All transplants and pre-transplant evaluation require prior authorizationIntersex Reassignment Surgery55970, 55980 YesCovered ServicePrior AuthorizationAll Inpatient Stays Facilities/HospitalsYesAll Network ExceptionsYesPartial HospitalizationYesPsychological/Neuropsy chological TestingPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsElectroconvulsive TherapyYesTranscranial Magnetic StimulationYesOutpatient ServicesPlease refer to the BCBSTX Medicare Advantage CPT PreAuthorization List for Authorization RequirementsPersonal care services and private duty nursing (home- or school-based) for children under age 21, who qualify under the EPSDT programSummary of Services and Behavioral Health UM requirements*Providers requesting services for Texas Medicare Advantage HMO Plans should contact Magellan for authorizationPlease view the comprehensive BCBSTX Medicare Advantage CPT Preauthorization Code List for a list of procedure codes that require review.

8 The PDF document allows for bookmarking and searching for the code. Press "CTRL" and "F" keys at the same time to bring up the search box.