bcbs of tennessee prior authorization process explained

BCBS of Tennessee has a prior authorization process in place to ensure that patients receive necessary treatments and services. This process requires providers to submit requests for approval before certain medical treatments can be administered.

The prior authorization process typically begins when a healthcare provider prescribes a treatment or service that requires approval. The provider will submit a request to BCBS of Tennessee, which will then review the request to determine if the treatment is medically necessary.

BCBS of Tennessee reviews requests based on medical necessity, which is determined by the patient's medical history and the treatment's potential benefits.

You can submit prior authorization requests for all lines of business 24/7 at Availity.com.

The prior authorization process has become simpler and faster thanks to new technology. This technology allows electronic submissions, which receive faster turnaround times compared to traditional methods.

Providers can track the status of each prior authorization on a dashboard in real-time, making it easier to monitor progress.

If you disagree with a decision made by BCBS of Tennessee, you can request a Peer-to-Peer discussion with a doctor to review details of the member's condition and care options.

You can also request an Expedited Appeal if the member is at a more urgent risk for severe health issues without the previously requested care or service. To request an expedited appeal, simply call the prior authorization number for the plan that covers your patient.

You have 18 months to submit a Provider Reconsideration Form if you need to provide additional information that may affect the decision. This form can be submitted if you disagree with a decision made by BCBS of Tennessee.

Non-emergent air transport requires prior authorization, so be sure to call Alacura directly at 1-877-561-2287 or fax to 1-877-561-4664. Calls and faxes are accepted 24/7.

You can verify benefits and request prior authorization at Availity.com, by phone at 1-800-924-7141, or fax to 1-866-558-0789.

Prior authorization is required for CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET, and CPT services, which you can verify and request at Availity.com, by phone at 1-800-924-7141, or by fax at (570) 595-4311.

Musculoskeletal prior authorization is needed for spinal surgery, joint surgery (hip, knee, and shoulder), and pain management, and can be requested at Availity.com or by fax at 1-866-747-0587.

Sleep studies performed in a lab setting for adults 18 years or older require prior authorization, but sleep studies at home do not. You can verify benefits and request authorization at Availity.com or fax the completed form to Commercial Utilization Management at 1-866-558-0789.

The Authorization Appeals Process can be a bit complex, but don't worry, I've got you covered.

You can request a Peer-to-Peer discussion with a doctor to review the member's condition and care options before starting the reconsideration and appeals process.

This discussion can help clarify the situation and may even resolve the issue without needing to go through the full appeals process.

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 request an Expedited Appeal if the member is at a high risk for severe health issues without the previously requested care or service.

To request an Expedited Appeal, simply call the prior authorization number for the plan that covers the patient.

If the reconsideration decision states that it was related to medical necessity, you may need to submit a Commercial Utilization Management Appeal Form.

You have the option to request binding arbitration if you're not satisfied with the formal appeal decision, but you'll need to check the Provider Dispute Resolution Procedure or the Provider Administration Manual for more information.

If you're a Blue Cross Blue Shield of Tennessee member, you might have noticed that certain prescription drugs require prior authorization. This means that your plan needs to approve the medication before you can fill the prescription.

Most members need prior authorization for certain drugs, but some plans may have different requirements. It's always a good idea to check your Schedule of Benefits to see which programs apply to you.

Quantity Management is another program that limits the amount of certain drugs your plan will cover. This can be frustrating if you're taking a medication that's suddenly restricted.

Some health plans require 90-day fills for maintenance drugs, which can be a relief if you take medication regularly. Maintenance drugs are prescription drugs you take on a long-term basis, and prescriptions for these products often can be filled for 90 days at a time.

Here are some key points about Drug Management Programs:

At BCBS of Tennessee, we're constantly looking for ways to make the prior authorization process easier and more efficient for our members and providers.

New technology has simplified and sped up the process, allowing providers to submit authorizations electronically.

This electronic submission method receives faster turnaround times, which is a big improvement over the old way of doing things.

Providers can now track the status of each prior authorization in real-time on a dashboard, giving them a clear picture of where things stand.

By using new technology, we've made it possible to process prior authorizations more quickly and accurately, which benefits everyone involved.