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BLUE CROSS AND BLUE SHIELD OF TEXAS (BCBSTX)OUTPATIENT PRIOR AUTHORIZATIONREQUIREMENTS BY PROCEDURE CODE FORADMINISTRATIVE SERVICES ONLY (ASO) MEMBERSGeneral Information: Procedures on the following pages may require prior authorization. These listsare not exhaustive. The presence of codes on this list does not necessarilyindicate coverage under the member benefits contract. Member contractsdiffer in their benefits. Consult the member benefit booklet or contact acustomer service representative to determine coverage for a specific medicalservice or supply. ASO groups may have specific prior authorizationrequirements. Providers should check eligibility and benefits through Availity or their preferred vendor to determine if a prior authorization is required.Not all requirements apply to each BCBSTX network (Blue Choice PPOSM, BlueEssentialsSM, Blue PremierSM, Blue Advantage HMOSM and MyBlue HealthSM).Updates to this list are announced routinely in the News and Updates section ofthe bcbstx.com/provider website.Selected procedures codes, within the outpatient service categories listed onthe Prior Authorization & Predeterminations page on the BCBSTX providerwebsite, may not be included in this procedure code list. It is imperative thatproviders check eligibility and benefits and verify prior authorizationrequirements through Availity or their preferred vendor for these categories.Refer to Prior Authorization & Predeterminations page on the BCBSTX providerwebsite for any specific ASO group prior authorization information.PRESS "CTRL" AND "F" KEYS AT THE SAME TIME ONTHE PROCEDURE LIST TO BRING UP THE SEARCH BOXBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association01/01/2020
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryNeurologyNeurologySelect Outpatient ProceduresSelect Outpatient ProceduresJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgerySelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPage 1 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryPain ManagementPain ManagementJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPage 2 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPain ManagementJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryArthroscopyArthroscopyArthroscopyPage 3 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryArthroscopyEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatCardiologySelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and logySelect Outpatient eroscopyLaparoscopy/HysteroscopyAbdominalSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient copySelect Outpatient ProceduresUrologicalPage 4 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure yNeurologyNeurologyPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPage 5 of 21
Procedure e/CategoryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementNeurologyNeurologyPain ManagementPain ManagementPain ManagementPain ologyNeurologyEyePage 6 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryEyeEyeNeurologyEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 7 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 8 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced anced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 9 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingCardiologyCardiologyAdvanced anced ImagingPage 10 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryAdvanced diologyCardiologyCardiologyCardiologyAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 11 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabPage 12 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabPage 13 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabEar, Nose and ThroatSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineOrthopedic (Musculoskeletal)Wound CareMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabAdvanced ImagingJoint, Spine SurgeryJoint, Spine SurgeryAdvanced ImagingJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementNeurologyPage 14 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure ologyRadiation OncologyRadiation OncologyCardiologyEar, Nose and ThroatEar, Nose and ThroatRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyNon-Emergent Fixed Wing Air AmbulanceNon-Emergent Fixed Wing Air AmbulancePage 15 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategoryNeurologyWound CareSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineRadiation OncologyAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingSleep MedicineSleep MedicinePage 16 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategorySleep MedicineSleep MedicineSleep MedicineNeurologyJoint, Spine SurgeryJoint, Spine SurgeryOrthopedic (Musculoskeletal)GastroenterologyOrthopedic (Musculoskeletal)Advanced ImagingAdvanced ImagingAdvanced ImagingPain ManagementWound CareAdvanced ImagingRadiation OncologyRadiation OncologySleep MedicineSleep MedicineSleep MedicineRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyMolecular and Genetic LabSelect Outpatient ProceduresEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatPage 17 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure 8092902839028490378C9014, J3590C9016, J3590C9024, J3590C9028, J3590C9257C9273C9466, J3590C9483C9484C9485C9489C9491C9492, J359001/01/2020Service/CategoryEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatCardiologyJoint, Spine SurgeryJoint, Spine SurgeryMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugPage 18 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure CodeC9493, tegorySpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugPage 19 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure e/CategorySpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugPage 20 of 21
BCBSTX OUTPATIENT PRIOR AUTHORIZATION REQUIREMENT BY PROCEDURE CODEFOR ASO MEMBERS EFFECTIVE JAN. 1, 2020Procedure 9354Q2040, J3590Q2041, J3590Q2043Q4081Q5102Q9986Q9989Q9991, J3590Q9992, J3590S0157S0189Service/CategorySpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugCPT Copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical AssociationAvaility is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchangeservices to medical professionals. Availity provides administrative services to BCBSTX. Aerial, iExchange and Medecision are trademarks of Medecision, Inc.,a separate company that offers collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representationsor warranties regarding any products or services offered by Availity or Medecision. The vendors are solely responsible for the products or services theyoffer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits, isnot a guarantee of payment. Benefits will be determined once a claim is received and will be based on among other things, the member’s eligibility and theterms 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 IDcard.Update History:Update DateDescription01/01/2020Original Posting Date01/01/2020Page 21 of 21
the Prior Authorization & Predeterminations page on the BCBSTX provider website, may not be included in this procedure code list. It is imperative that providers check eligibility and benefits and verify prior
