Bcbs Precert Process and Medical Guidelines

BCBS precert is a process that requires prior approval for certain medical procedures.

BCBS precert is typically required for services that are considered high-cost or high-risk, such as surgeries or hospital stays.

To initiate the precert process, providers must submit a precert request to BCBS, which includes detailed information about the proposed treatment plan.

The precert process can take several days to several weeks to complete, depending on the complexity of the case.

BCBS has established medical guidelines to determine which services require precertification.

Related reading: Bcbs Ga Medical Policies

Precertification is a crucial step in the healthcare process, and it's essential to understand how it works. BCBSKS requires precertification for inpatient admissions, unless it's a medical emergency, a life-threatening condition, obstetrical care, or outside the 50 United States.

You can submit a precertification request or view the status of an existing request by visiting the secure pre-certification section. For inpatient medical stays, call 800-782-4437, and for inpatient mental health stays, call 800-952-5906.

To verify coverage or benefits, or to determine precertification or authorization requirements, call 800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.

Broaden your view: Does Medical Ask for Bank Statements

The Authorization Pre-Check tool is a game-changer for determining if a prior authorization is required for a BCBSWY member upfront. Simply enter the requested information in Availity, and you'll get a yes or no answer.

This tool is exclusive to BCBSWY members, so make sure you're working with the right demographic. Keep in mind that this is not a substitute for the actual prior authorization process, but rather a quick check to see if one is required.

If a prior authorization is required, you can complete a request through Availity or submit a Prior Authorization Request Form. Medical records will be necessary with each submission.

To mark a request as urgent, you'll need to have a legitimate reason, such as a life or limb threatening situation, severe pain, or a medical emergency. Non-urgent requests marked as urgent will only delay processing.

BCBSWY's clinical staff reviews prior authorization requests from Providers using their Medical Policies, which are available online for searching by title, CPT code, and identification number.

Non-urgent prior authorization requests are processed within 5 calendar days from date of receipt, while urgent requests are processed within 72 hours from date of receipt.

The Provider, rendering facility, and member are notified in writing of the determination via U.S. Mail.

A fax response is immediately sent once a determination has been made.

Here's a summary of the processing timeline:

BCBS has a comprehensive set of medical policies and guidelines that outline the requirements for precertification. These policies are designed to ensure that patients receive necessary care while minimizing unnecessary expenses.

BCBS requires precertification for certain high-cost treatments, including bone marrow transplants, lung transplants, and certain types of cancer treatments. This means that patients must obtain prior approval from BCBS before undergoing these procedures.

If the medical policy criteria isn't met, Blue Cross Blue Shield of Wyoming recommends authorizing procedure codes associated with their medical policies.

This means that if you're a healthcare provider, you should get an authorization from BCBSWY before performing a procedure, especially if it's subject to a medical policy.

BCBSWY will deny claims for procedure codes subject to medical policy if the medical policy criteria aren't met and an authorization isn't on file.

This can happen for two main reasons: deny for no authorization or deny for not medically necessary.

BCCHP makes decisions about your care based on need and benefits.

Your doctors will use medical codes to check Prior Authorization needs. These codes are used by PCPs and specialists to determine if additional approval is required.

BCCHP doctors and staff use clinical criteria to make sure you get the health care you need. This involves reviewing your medical situation to determine the best course of action.

Medical Policies are used to guide care decisions. These policies are based on scientific and medical research.

Your doctor will use Prior Authorization tools, clinical review criteria, and BCCHP Medical Policies to make a decision about your care.

BCBS has specialized programs in place to make the precert process more efficient.

One of these programs is the "BCBS Precertification Program for High-Cost Services", which requires precertification for certain high-cost services.

This program helps to ensure that patients receive necessary care while also controlling costs.

The EviCore Program is a specialized program that provides certain utilization management prior authorization services for Medicare members.

BCBSNM has contracted with eviCore Health to offer this program, which is an independent company that provides specialty medical benefits management.

You can refer to the eviCore implementation site to access the applicable CPT/HCPCS code list and radiation therapy physician worksheets for your specific health plan.

Services requiring prior authorization through eviCore include Molecular and Genomic Tests, Musculoskeletal, Outpatient Advanced Radiology, Outpatient Medical Oncology, Outpatient Sleep, and Outpatient Specialty Drug.

Here are the specific benefit plans that require prior authorization through eviCore:

You can obtain prior authorization for these services through one of two methods: the eviCore Healthcare Web Portal or by calling toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.

The AIM Specialty Health Program is a valuable resource for healthcare providers. AIM is an independent company contracted with BCBSNM to provide certain utilization management prior authorization services.

If you need to request prior authorization for services like molecular and genomic tests, radiation therapy, or advanced imaging, you'll want to use the AIM ProviderPortal. This portal allows for self-service, smart clinical algorithms, and in many cases, real-time determinations.

The AIM ProviderPortal also lets you check prior authorization status and increase payment certainty. Faster pre-service decision turnaround times are another benefit of using this portal.

Services requiring prior authorization through AIM include molecular and genomic tests, radiation therapy, advanced imaging, musculoskeletal treatments, sleep studies for certain members, and select outpatient procedures.

To submit the New Mexico Uniform Prior Authorization Form, providers can use the AIM ProviderPortal. Simply check the box to submit the form and upload it through the portal.

Here are the services requiring prior authorization through AIM:

Outpatient Services requiring prior authorization include Advanced Imaging / Radiology, Molecular Genetic Lab Testing, Musculoskeletal - Joint, Spine Surgery, and Musculoskeletal - Pain services for commercial and retail fully-insured members.

These services are subject to prior authorization through AIM or BCBSNM, depending on the specific service. For example, Radiation Therapy / Radiation Oncology services are subject to prior authorization through AIM.

Some outpatient services, such as Sleep services, require prior authorization through AIM for ASO members, while others, including Select Outpatient Services, require prior authorization through BCBSNM.

Outpatient Services often require prior authorization for certain procedures.

Some of these services include Advanced Imaging / Radiology, Molecular Genetic Lab Testing, and Musculoskeletal - Joint, Spine Surgery.

These services are subject to prior authorization for all commercial and retail fully-insured members, but the specifics may vary for self-funded health plans.

For example, services like Sleep and Select Outpatient Services may require prior authorization for some members, but not others.

If you're unsure about which services require prior authorization, it's best to check with your health plan provider or Availity.

Broaden your view: Medical Insurance Claims Processing Steps

If you're an out-of-area member, you'll need to follow a different process for precertification.

To view the out-of-area Blue Plan's general precertification/authorization information, enter the first three letters of the member's identification number on the Blue Cross Blue Shield ID card, and click "GO."

You'll then need to review the criteria and fax or email a completed prior authorization form.

Here's a list of contact numbers for out-of-area precertification requests:

Remember to verify coverage or benefits or determine precertification or authorization requirements for a particular member by calling 800-676-BLUE or sending an electronic inquiry through your established connection with your local Blue Plan.

If you need to return a medication or check the status of a prior authorization, you can do so through CoverMyMeds. You can complete the prior authorization form electronically to initiate the process.

To check the status of a prior authorization, you can use the links provided by BCBSKS to access their pharmacy medical policies. These policies are maintained through their pharmacy benefit manager, Prime Therapeutics.

For another approach, see: Bcbs Preferred Pharmacy

If you're looking for pharmacy medical policies specific to a medication, you can use the links below to find them.

You can also check the status of a prior authorization for specific medications, such as compounded prescriptions greater than $100, germline genetic testing, or very high cost drugs and therapies.