BCBS Federal Prior Authorization Process and Requirements

The BCBS federal prior authorization process is a crucial step in ensuring that patients receive the necessary treatments and medications. The process is designed to prevent unnecessary or excessive care.

BCBS federal prior authorization requirements vary depending on the specific service or treatment being requested. Typically, patients or healthcare providers must submit a prior authorization request to BCBS, which includes detailed information about the treatment or service.

BCBS federal prior authorization requirements include providing documentation of medical necessity, such as a diagnosis or treatment plan. This documentation is essential for the prior authorization review process.

In most cases, BCBS federal prior authorization decisions are made within 24-48 hours of receiving the request. However, some requests may take longer to process, especially if additional information is required.

BCBS FEP administrators across the country are inconsistently implementing the updated policy, leading to automatic denials for hearing aids when a patient's hearing loss is 40 dB or less without individual review.

Audiologists are struggling to figure out the prior approval protocol from each BCBS FEP administrator, which is leaving them scrambling to help their clients efficiently.

BCBS FEP administrators are not providing clear guidance on the new process, making it difficult for audiologists to navigate the system.

BCBS FEP administrators across the country are still inconsistently implementing the updated policy on hearing aid coverage.

The updated guideline clarifies that coverage is considered medically necessary for hearing loss above 40dB, but it also allows for individual review for hearing loss of 40 decibels or less with a prescription from a licensed healthcare provider.

Automatic denials for hearing aids are still occurring for patients with hearing loss of 40 dB or less without individual review.

There is a concerning lack of information on prior approval protocol from each BCBS FEP administrator, leaving audiologists and healthcare providers scrambling to figure out the process.

Audiologists are experiencing frustration and inefficiency due to the inconsistent implementation of the updated policy.

ASHA has sent a letter to the national BCBS FEP to clarify the nuances of the hearing aid policy and is seeking support from the federal government's Office of Personnel Management (OPM) to ensure proper implementation.

BCBS FEP administrators need to provide clear guidance on the new process to avoid further confusion and delays in patient care.

If you're dealing with a prior authorization issue, it's essential to know what codes are required for approval. The prior authorization list is a crucial document that outlines the necessary codes for Blue Shield and Federal Employee Program (FEP) members.

The list can be found online as a PDF document, weighing in at 213 KB. This makes it easy to access and reference when needed.

If you're a federal employee with Blue Cross/Blue Shield, you'll need to follow different rules for getting prior authorization.

Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) should call (800) 633-4581 to obtain prior authorization for outpatient procedures and treatment requiring an inpatient stay.

If you're part of the Federal Employee Program, you'll need to follow different rules for getting prior authorization.

The Federal Employee Blue Cross/Blue Shield Service Benefit Plan has its own set of requirements for prior authorization.

To get prior authorization for outpatient procedures, call (800) 633-4581.

For treatment requiring an inpatient stay, you'll also need to call (800) 633-4581 to get prior authorization.

As of January 1, 2024, the Federal Employee Program has updated its prior authorization requirements and benefits.

Some procedures now require prior authorization, including hearing aids, genetic testing, Proton Beam Therapy, Stereotactic Radiosurgery, Stereotactic Body Radiation Therapy, certain High-Cost High Dollar drugs, and all gene therapy and CAR-T drugs.

You can submit a request for prior authorization via Availity Essentials or by faxing the Recommended Clinical Review form to 877-404-6455.

All transplants require prior authorization, except for corneal transplants.

Prior authorization is also required for Gender Affirming Care, artificial insemination, and in vitro fertilization related drugs.

If you have any questions, call the number on the member's BCBSIL ID card.

Here are some key updates at a glance:

Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits.

Some weight loss GLP-1 drugs are no longer covered due to the 2025 tier change.

Starting in 2025, Wegovy (semaglutide) will not be covered for FEP Blue Focus members. This change affects those who rely on this medication for weight loss.

Some GLP-1 weight loss drugs are no longer covered due to the 2025 tier change.

Wegovy (semaglutide) will not be covered for FEP Blue Focus members starting in 2025.

If your GLP-1 formulary exception criteria was denied, you can discuss other GLP-1 and weight loss medications on the formulary with your healthcare provider.

You should refer to the denial letter mailed to you and your provider to understand your appeal rights and steps you may take.

You can explore alternative options with your healthcare provider if you're unable to get the non-covered weight loss GLP-1 medication.

You can still obtain a weight loss GLP-1 that is not covered or excluded, but your healthcare provider must submit a formulary exception request on your behalf.

If your case aligns with the formulary exception guidelines, approval for your weight loss GLP-1 will be granted. Please note that a formulary exception does not change your out-of-pocket costs.

You or your provider can download the FEP Traditional Formulary Exception Form or FEP MPDP Formulary Exception Form to submit a request. Your provider can also call 1-877-727-3784 or 1-855-344-0930 for assistance.

For FEP Blue Basic and FEP Blue Standard, Zepbound (tirzepatide) would be Tier 3 non-preferred.

If your GLP-1 formulary exception criteria was denied, you can still discuss other GLP-1 and weight loss medications on the formulary with your healthcare provider.

You can refer to the denial letter mailed to you and your provider for information on your appeal rights and steps you may take.

If you and your provider decide that you must be on the non-covered/excluded weight loss GLP-1, your provider can request the formulary criteria and call 1-877-727-3784 or 1-855-344-0930 for more information.

If your GLP-1 formulary exception criteria was denied, don't worry, there are still options to explore.

You can discuss the other GLP-1 and weight loss medications on the formulary with your healthcare provider.

Please refer to the denial letter mailed to you and your provider that will explain your appeal rights and steps you may take.

If your GLP-1 formulary exception criteria expired, you need to discuss other GLP-1 and weight loss medications on the formulary with your healthcare provider.

You can't just stop taking your medication, so your provider will need to request a new formulary exception to continue accessing your medication in 2025.

If you're a Blue Shield or Federal Employee Program (FEP) member, you'll need to check the prior authorization list to see if a specific medication or treatment requires approval.

The prior authorization list is available as a downloadable PDF document, which is a useful resource for staying on top of the latest requirements.

To access the list, simply click on the provided link, which will direct you to the document. The PDF document is a substantial 213 KB in size, so be sure to give it a few moments to load.

By checking the prior authorization list, you can ensure that you're getting the treatments and medications you need in a timely manner.