bcbs Pharmacy Prior Authorization Requirements and Guidelines

BCBS requires prior authorization for certain medications, including brand-name and specialty medications, as well as those with specific usage or dosing guidelines. This ensures that patients receive the most effective and cost-efficient treatment possible.

To initiate the prior authorization process, prescribers must submit a request to BCBS, including the patient's medical history and the reason for the medication. This information helps BCBS assess the medical necessity of the medication and determine whether it's covered under the patient's plan.

BCBS typically responds to prior authorization requests within 24-48 hours, although this timeframe may vary depending on the complexity of the request.

Precertification serves as a checks and balances system to ensure the proper use of insurance benefits.

Precertification and prior authorization help health insurance companies control the risk of fraud and inappropriate use.

This helps keep the cost of health care premiums affordable for everyone.

Precertification and prior authorization ultimately aim to ensure that insurance benefits are used correctly.

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Precertification and prior authorization may be required for certain treatments or services, but it depends on your health insurance plan.

You can check your Benefit Booklet in your Blue Connect℠ member portal for specific information about your insurance plan, such as Blue Cross NC members.

Prior review and authorization requirements may vary depending on your health insurance plan.

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Prior review is a process that must be approved by your insurance provider, Blue Cross NC, before they'll cover certain prescription medications, medical procedures, or health care services. This process is also known as prior approval, prior authorization, prospective review, certification, or precertification.

In an emergency, prior review isn't required, but it's essential to notify Blue Cross NC of an urgent or emergency admission by the second business day after the admission.

The prior review process typically includes several steps, such as your health care provider submitting the prior authorization to your health insurance company, the company reviewing the authorization and deciding if it should be approved or denied, and sending the decision back to your provider.

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Approved prior reviews are sent back to your provider, and your provider and/or your insurance company will let you know if it's approved. Denied prior reviews are sent back to your provider with a reason for denial and information about how to submit an appeal to the insurance company.

You must get a prior review approved before the services, treatments, or prescriptions are provided.

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If you've received a denied prior authorization, don't worry, you have the right to appeal. Your insurance provider may deny the authorization if they believe the service, treatment, or prescription isn't medically necessary, but you can submit an appeal to the insurance company.

You can submit prior authorization requests for all lines of business 24/7 at Availity.com, or if you're a Network Provider, you can use the myBlue Provider website to request a prior authorization. If you're a non-network or out-of-state provider, you can begin a Prescription Drug Prior Authorization Request through a link on the myBlue Provider website.

For more insights, see: Prior Authorization Website

If you disagree with a decision made by your insurance provider, you can request a Peer-to-Peer discussion with a doctor to review details of your condition and care options. Expedited Appeals are available for members who are at a more urgent risk for severe health issues without the previously requested care or service.

Here are the steps to follow for a formal appeal:

If your insurance provider denies a prior authorization, you have the right to appeal the decision. Your provider can submit an appeal to the insurance company, giving you another chance to get the service, treatment, or prescription you need.

The insurance company will review the appeal and make a decision based on the existence of coverage and the appropriateness of care. You can request a Peer-to-Peer discussion with a doctor to review the details of your condition and care options before beginning the appeals process.

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You can request an expedited appeal if you're at a higher risk for severe health issues without the previously requested care or service. This can be done by calling the prior authorization number for your plan.

If you disagree with the decision or need to provide additional information, you can submit a Provider Reconsideration Form within 18 months of the initial denial. This form is available for you to use, and it's a crucial step in the appeals process.

Here are the steps to follow for the appeals process:

Requests can be a necessary part of the healthcare process, especially when it comes to getting prior authorization for certain medications or treatments.

If you're a Network Provider, you can request a prior authorization through the myBlue Provider website. Non-network or out-of-state providers can start a Prescription Drug Prior Authorization Request through a link provided by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

You can submit prior authorization requests for all lines of business 24/7 at Availity.com. This is a convenient option for providers who need to request prior authorization quickly.

To request prior authorization, your healthcare provider will need to submit the request to your insurance company. This can be done online or over the phone, depending on the specific requirements of your plan.

Here are the phone numbers to call for prior authorization requests:

You can access the Prior Authorization Lookup tool to view the most recent updates.

The Utilization management authorization request form can be used to submit requests for prior, concurrent, or retrospective review.

To submit prior authorization requests electronically, you can use your Electronic Health Record tool software or one of the online portals listed.

Access Control is a crucial aspect of managing healthcare services, and Blue Cross Complete has implemented various measures to ensure that access is controlled and authorized. You can submit prior authorization requests electronically through your Electronic Health Record tool software or online portals.

To access the Medical Authorizations portal, you'll need to log in through NaviNet, located on the Workflows menu. This portal allows you to submit and inquire about existing authorizations, verify if no authorization is required, and even receive auto approvals in some cases.

Some services, such as non-emergency outpatient diagnostic imaging, require prior authorization from Evolent, formerly National Imaging Associates, Inc. You can find resources and information on how to obtain prior authorization for these services on the RadMD.com website or by calling Evolent at 1-800-424-5351.

Here are some additional services that require prior authorization:

You can find pharmacy medical policies specific to a medication list using the links below:

You can access a range of features through NaviNet, including receiving real-time news alerts and viewing member information.

To get started, log on to the Blue Cross Complete payer-provider portal, NaviNet.

You can use NaviNet to submit authorization requests and view gaps in care reports.

The NaviNet Medical Authorizations Participant Guide and Frequently Asked Questions can help you learn more about using the system.

To review commonly asked questions, refer to the NaviNet Medical Authorizations Frequently Asked Questions (PDF).

You can also use NaviNet to check the status of claims and retrieve and report on specific Care Gap changes.

Here are some of the key features of NaviNet: