Update to Current Procedural Terminology® (CPT) Codes for Prior Authorization for Medicare Members, Effective July 1

April 21, 2022

What’s Changing: Blue Cross and Blue Shield of Montana (BCBSMT) is changing prior authorization requirements for Medicare members to reflect new, replaced or removed codes due to updates from Utilization Management or the American Medical Association (AMA).

Important Reminder: Always check eligibility and benefits first through the Availity® Provider Portal or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.

A summary of changes is included below:

  • July 1, 2022 – Addition of one Outpatient Sleep code to be reviewed by eviCore
  • July 1, 2022 – Addition of two Outpatient Specialty Drug codes to be reviewed by eviCore
  • July 1, 2022 – Addition of Outpatient Specialty Drug, Susvimo, reported with codes J3590 or C9399 to be reviewed by eviCore
  • July 1, 2022 – Addition of Outpatient Specialty Drugs, Cortophin and Vyvgart reported with codes J3490, J3590 or C9399 to be reviewed by eviCore

More Information: For a revised list of codes go to the Medicare Advantage section of our provider website.

Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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 BCBSMT.

eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSMT.

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.