Prior authorization and referral requirements for HealthSelect of Texas medical plans

November 06, 2024

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As of Sept. 1, 2024, the HealthSelect^SM medical plans administered by Blue Cross and Blue Shield of Texas (BCBSTX), including Consumer Directed HealthSelect^SM, no longer require prior authorizations for any covered health services. However, to get in-network benefits and save the most money, the plan still requires HealthSelect of Texas participants to get a referral from their primary care provider (PCP) on file with BCBSTX, before they receive care from a specialist.

Understanding the difference between prior authorization and referrals can help you get the most value from your medical plan benefits.

What is the difference between prior authorization and a referral?

Prior authorization is the review process that the HealthSelect plans have used in the past to determine whether certain services or procedures are medically necessary and covered under the medical plan. As noted, the plans no longer require prior authorization for any covered health services.

A referral is different from prior authorization. A referral is a written order submitted to BCBSTX from your PCP to receive care from a specialist. For most services, if you are enrolled in the HealthSelect of Texas medical plan, you need to get a referral before you get most medical care from anyone except your PCP. If you don't have a valid referral on file with BCBSTX before seeing a specialist, you will pay more because your visit will be considered out-of-network. Learn more about referrals.

To further explain the difference, here's a hypothetical situation.

Randall, a HealthSelect of Texas medical plan participant, has been experiencing pain and numbness in his wrists and hands for a few months. He thinks he may have a repetitive stress injury like carpal tunnel syndrome. Randall wants to see an orthopedic specialist. Because referrals are still required for in-network benefits in his health plan, he must first see his PCP to get a referral to an in-network orthopedist.

After his PCP submits the referral to BCBSTX, Randall visits the specialist, who recommends additional testing to diagnose the condition and help determine the best treatment. Although the additional testing would have required a prior authorization in the past, it no longer does. Randall can get the procedure without a prior authorization on file with BCBSTX.

Note: The Consumer Directed HealthSelect, HealthSelect^SM Out-of-State and HealthSelect^SM Secondary plans do not require referrals. However, referrals are still required on the HealthSelect of Texas plan. In addition, prior authorizations are still required for some medications in the HealthSelect Prescription Drug Program.

Providers may still request an optional pre-service clinical review.

Certain covered health services continue to require medical necessity reviews based on medical policies. Medical policies are guidelines that help determine coverage for medical procedures, drugs, devices and other services. These policies are based on scientific literature guidelines from specialty societies and other health care organizations.

While pre-service clinical reviews are not required, your providers may request a review by BCBSTX prior to providing care to ensure the services are medically necessary. In-network providers cannot bill you for services that are not medically necessary unless you agree in writing prior to receiving the services.

If you get care from an out-of-network provider, you may be responsible for more of the cost, including services determined not to be medically necessary.

For more information:

If you have questions about your medical plan benefits or need help finding in-network providers, you can reach out to a BCBSTX Personal Health Assistant over the phone, via live chat or secure messaging. Call a BCBSTX Personal Health Assistant toll-free at (800) 252-8039 (TTY: 711), Monday - Friday. 7 a.m. - 7 p.m. and Saturday, 7 a.m. - 3 p.m., or via live chat Monday - Friday, 8 a.m. - 5 p.m. CT. Secure messaging is available 24 hours a day, and you will receive an email response in one to two days. Secure chat and secure messaging are available once you are logged in to Blue Access for Members^SM.