BlueCross BlueShield of Tennessee
Prior Authorization List Codes Under Management:
High Tech Imaging (HTI)
Overview
Starting January 2, 2025, Cohere Health, a patient journey optimization company, is designated as the preauthorization and utilization management vendor for BlueCross BlueShield for High Tech Imaging services.
Practices must use Cohere when requesting preauthorizations for any of the procedure codes or services listed in the table below.
Please note that issuance of an approval decision for any preauthorization request does not represent a guarantee of payment. Always refer to BlueCross BlueShield of Tennessee’s official Prior Authorization Lists (PAL) for the most up to date prior authorization requirements, coverage policies, and related plan policies. In addition to the procedure codes, other request criteria may impact submission requirements.
Please note: If you are submitting a Medicaid (BlueCare) retro-authorization, you must indicate that it is being submitted for one of the following reasons:
The Enrollee did not provide BlueCare Tennessee insurance information
The Enrollee ID Card was not issued
Medicare was incorrectly documented as primary
There was a coverage issue
Failure to do so will result in your authorization request being admin voided.
Service | Procedure Code |
Cardiac Imaging | 78453, 78454, 78451, 78452, 78491, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496, 75571, 93306 |
Diagnostic Imaging | 70336, 70450, 70460, 70470, 70471, 70472, 70473, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75577, 75635, 76376, 76377, 76380, 76390, 76391, 77046, 77047, 77048, 77049, 77084, 78429, 78430, 78431, 78432, 78433, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, C8900, C8901, C8902, C8903, C8905, C8906, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, C9762, C9763, C9791, G0219, G0235, G0252, G0680, S8037, S8042, S8092 |
Magnetic Resonance Imaging (MRI) | 74712, 74713, 76498, 0648T, 0649T, 77021, 0609T, 0610T, 0611T, 0612T, 77022, 0698T, 0697T, S8035, 70559, 70557, 0724T, 70558, 0723T, A9579 |
3D Imaging | 0694T, 0693T, 0422T, 0561T, 77061, 77062, G0279, 0562T, 0559T |