BCBS Medicare Advantage Prior Authorization Process and Appeals Made Easy

Navigating the BCBS Medicare Advantage prior authorization process can be complex, but it doesn't have to be.

To start, it's essential to understand that BCBS Medicare Advantage requires prior authorization for certain services, including durable medical equipment, injectable medications, and some procedures.

Prior authorization can be requested online, by phone, or through the BCBS Medicare Advantage mobile app.

BCBS Medicare Advantage has a dedicated team to handle prior authorization requests and appeals, ensuring timely and efficient processing.

The prior authorization process can be a bit of a headache, but understanding how it works can make it more manageable. Prior authorization is required for certain services and medications, and it's usually necessary to get approval before receiving treatment.

The timeline for prior authorization varies depending on the specific service or medication. For example, Blue Cross and Blue Shield of Vermont requires a response to all prior approval requests within two business days, whether they're marked "urgent" or not. However, marking a request as "urgent" doesn't guarantee immediate review, and state guidelines permit up to 48 hours to review urgent requests.

To request prior authorization, you can use various methods, including electronic requests through Availity or CoverMyMeds, faxing completed forms, or making phone calls to the prior authorization number on the member's ID card. For some services, like non-emergent air transport, you may need to contact a third-party provider directly.

Here are some common methods for requesting prior authorization:

It's essential to remember that prior authorization does not guarantee payment, and all payments are subject to determination of the insured person's eligibility and other policy provisions.

Precertification is a process that helps ensure the proper use of insurance benefits. It's a checks and balances system that helps health insurance companies control the risk of fraud and inappropriate use, keeping the cost of healthcare premiums affordable for everyone.

Precertification is required for inpatient admissions, unless the admission is for a medical emergency, a life-threatening condition, for obstetrical care, or occurs outside the 50 United States. This includes all inpatient medical stays and mental health stays, which can be submitted through secure login with Availity or by calling specific phone numbers.

To submit a request or view the status of an existing request, visit the secure pre-certification section. Members of some group health plans may have terms of coverage or benefits that differ from the general policies of BCBSKS, so it's essential to verify coverage or benefits or determine precertification or authorization requirements for a particular member.

You can call 800-676-BLUE to verify coverage or benefits or determine precertification or authorization requirements for a particular member. Alternatively, you can send an electronic inquiry through your established connection with your local Blue Plan.

Here are the phone numbers to submit a request for inpatient medical stays and mental health stays:

Authorization Appeals Process is available for providers to review and discuss a member's condition with a doctor, known as a Peer-to-Peer discussion.

This discussion can help determine the appropriateness of care and coverage.

Expedited Appeals are available for members at a higher risk for severe health issues, which can be requested by calling the prior authorization number.

If you disagree with a decision or need to provide additional information, you can submit a Provider Reconsideration Form within 18 months of the initial denial.

You can also file a formal appeal by submitting a Provider Appeals Form, which may require additional information depending on the reconsideration decision.

Let's break down some common terms defined in your member contract.

A pre-service claim is a request for a claim's decision when prior authorization of services is required by BCBSKS.

Pre-service requests are a courtesy review performed by BCBSKS to determine coverage, including requests for services, supplies, or prescription drugs with a medical policy or deemed experimental/investigation.

Pre-service requests are not required for all services, but they can help ensure that high-cost items or services are covered.

If the service is being performed inpatient, prior authorization is always required.

The appeals process is a crucial step in resolving disputes with healthcare providers. You have the option to request a Peer-to-Peer discussion with a doctor to review details of the member's condition and care options before beginning the reconsideration and appeals process.

Expedited appeals are available for members who are at a more urgent risk for severe health issues without the previously requested care or service. You can request an expedited appeal by calling the prior authorization number for the plan that covers your patient.

If you disagree with a decision, you can submit a Provider Reconsideration Form within 18 months of the initial denial. This form is required to initiate the reconsideration process.

You can file a formal appeal by submitting a Provider Appeals Form to the relevant authority. Please note that timelines for each line of business can be found in a helpful guide.

If the reconsideration decision states that the reconsideration was related to medical necessity, you may be directed to the Commercial Utilization Management Appeal Form. This form is required to continue the appeals process.

If you're not satisfied with the formal appeal decision, you have the option to request binding arbitration. This can be done through the Provider Dispute Resolution Procedure or the Provider Administration Manual, depending on the plan that covers your patient.