BCBS Prior Authorization and Insurance Coverage

Author

Posted Jan 1, 2025

Reads 1.1K

A Health Insurance Spelled on Scrabble Blocks on Top of a Notebook Planner
Credit: pexels.com, A Health Insurance Spelled on Scrabble Blocks on Top of a Notebook Planner

Blue Cross Blue Shield (BCBS) has specific requirements for prior authorization and insurance coverage. This means that certain treatments, medications, or services require approval before they can be covered by your insurance.

BCBS has a list of covered services and treatments, which can be found on their website or by contacting your insurance provider directly.

Prior authorization can be requested through the BCBS website or by contacting their customer service number.

The approval process typically takes a few days to a week, but can vary depending on the complexity of the case.

Prior Authorization Process

The prior authorization process is a crucial step in ensuring you get quality medical care while keeping health care costs under control. Insurance companies use prior authorizations to help keep health care costs under control while making sure members get quality medical care.

Your health care provider will submit the prior authorization to your health insurance company, which will then review it to decide if it should be approved or denied. This review process typically includes several steps.

Credit: youtube.com, [WEBINAR] BCBS Federal Prior Authorizations: Unlocking the Code!

Here's a breakdown of the prior review process:

  • Your health care provider will submit the prior authorization to your health insurance company.
  • Your health insurance company will review the prior authorization and decide if it should be approved or denied.
  • Approved prior reviews are sent back to your provider. Your provider and/or your insurance company will let you know if it is 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 prescription are provided.

You'll receive notification from your provider and/or insurance company if your prior authorization is approved or denied. It's essential to get a prior review approved before receiving any services, treatments, or prescriptions.

Understanding Prior Authorization

Prior authorization is a process used by insurance companies to review and approve medical treatments, services, and prescription drugs before they are provided to a patient. This helps keep healthcare costs under control while ensuring members receive quality care.

The prior review process typically involves several steps, including the healthcare provider submitting a prior authorization request to the insurance company, which then reviews the request to decide if it meets the plan's guidelines. If approved, the prior review is sent back to the provider, and the patient is informed of the decision.

Insurance companies use prior authorizations to ensure that services and treatments are medically necessary and align with the plan's guidelines. If a service or treatment is not medically necessary, it may not be covered.

For more insights, see: Fehb and Medicare Part B

Medically Necessary

Credit: youtube.com, Understanding Prior Authorization

Medically necessary services are those that are needed to treat a medical condition. This is according to Blue Cross NC medical policy.

To be covered, a service must be deemed medically necessary. If a service or treatment isn't medically necessary, it may not be covered.

Here are some examples of what might be considered medically necessary:

  • The service is medically necessary (needed) according to Blue Cross NC medical policy.
  • If the service or treatment isn't medically necessary (elective), you may not be covered.

Predetermination

Predetermination is an elective process that allows you to assess benefits and medical necessity before rendering services. It's not a substitution for prior authorization, which is mandatory for certain services.

A predetermination is only available for certain services not subject to prior authorization. For example, predetermination may not be available for complete or partial bony impacted teeth.

To request a predetermination, you'll need to fill out the entire Predetermination Request form. This form requires procedure code(s) and diagnosis code(s), and if applicable, left, right, or bilateral information.

You can submit a predetermination request electronically using Availity's Attachments tool or by faxing the completed form along with supporting documentation.

Credit: youtube.com, How Health Insurance Prior Authorization Works

It's essential to note that a predetermination does not guarantee payment. Payments are subject to determination of the insured person's eligibility, payment of required deductibles, copayments, and coinsurance amounts, eligibility of charges as covered expenses, application of the exclusions and limitations, and other provisions of the policy at the time services are rendered.

Here are the steps to submit a predetermination request:

  • Fill out the entire Predetermination Request form.
  • Provide procedure code(s) and diagnosis code(s).
  • Include left, right, or bilateral information if applicable.
  • Attach original photos or digital color copies that clearly show the affected area of the body, if indicated.
  • Submit the request online or by fax.

By following these steps, you can ensure a smooth predetermination process and receive a final outcome notification when the review is complete.

Submitting Requests

To submit a request for prior authorization, you'll need to confirm if it's required using Availity or your preferred vendor. This will determine if prior authorization will be obtained through Blue Cross Blue Shield Oklahoma (BCBSOK) or a dedicated vendor.

You can use BlueApprovR to request recommended clinical review (predetermination) for certain services, including inpatient and outpatient medical and surgical services, and specialty pharmacy drugs. To do this, select Claims & Payments from the navigation menu, then Send Attachment, and finally Predetermination Attachment.

Credit: youtube.com, Submitting Successful Prior Authorizations

The process for submitting a predetermination request is similar, but you'll need to download and complete the Recommended Clinical Review (Predetermination) Request Form. This form requires all applicable fields to be filled out, including the member/patient's group number, ID number, and date of birth.

If you're submitting a fax request, place the Recommended Clinical Review (Predetermination) Request form on top of other supporting documentation, and include any additional comments if needed. You can also submit online or by mail, but be sure to follow the instructions carefully to avoid delays.

Here are some important tips to keep in mind:

  • Do not send in duplicate requests, as this may delay the process.
  • If photos are required for review, they should be mailed to the address indicated on the form, not faxed.
  • For major diagnostic tests, include the patient's history, physical, and any prior testing information.
  • Always check benefits before submitting a predetermination, as it may not be available for all procedures.

By following these steps and tips, you can ensure that your requests are processed efficiently and effectively.

Provider Information

If you're a healthcare provider, it's essential to understand the prior authorization process with Blue Cross NC. To request a prior review and authorization, simply call Blue Cross NC Utilization Management at 800-672-7897.

The utilization management team is available Monday through Friday, from 8 AM to 5 PM ET. This is a great resource to have when you need to get a patient's treatment approved in a timely manner.

Here's an interesting read: Dental Insurance in North Carolina

Approved Location

Credit: youtube.com, How to Submit Additional Opportunities as an Approved Provider

To ensure that your medical services are covered, it's essential to have them performed in the right health care setting. This is often referred to as an approved location.

The service must be medically necessary, and the provider performing it must be correctly identified as in- or out-of-network. This information is crucial for your insurance coverage.

Here are the key factors to consider when determining an approved location:

  • The medically necessary service is performed in the right health care setting.
  • The performing provider is correctly identified as in- or out-of-network.

Out-of-Network Providers

If you're planning to see a provider outside of your network, make sure they've asked Blue Cross NC for prior review before performing any services.

Members are responsible for ensuring out-of-network providers have requested prior review from Blue Cross NC before a service is performed.

This applies to out-of-state providers who contract with other Blue Cross Blue Shield plans, such as those participating in the BlueCard program.

You'll need to verify that these providers have obtained prior review from Blue Cross NC to avoid any unexpected costs.

Special Vendors

Credit: youtube.com, How to Find The Perfect Patient Statement Services Vendor

If you need to request a prior authorization for radiology or high-tech imaging services, you can call 855-569-6749 or visit www.RadMD.com. Evolent manages these requests on behalf of BlueChoice HealthPlan.

Avalon handles prior authorizations for laboratory services. To review the current list of required authorizations, you can use the PAS Portal, call 844-227-5769, or fax the request form to 813-751-3760.

CarelonRx manages prior authorizations for certain medications. If you need to request authorization, you can call 833-255-0646 or fax 833-263-2871.

Here are the contact details for the special vendors:

  • Evolent: 855-569-6749, www.RadMD.com
  • Avalon: PAS Portal, 844-227-5769, 813-751-3760 (fax)
  • CarelonRx: 833-255-0646, 833-263-2871 (fax)

Insurance and Coverage

You can check your benefits through the voice response unit or My Insurance Manager to determine if prior authorization is required. Healthy Blue requires prior authorization for certain procedures and durable medical equipment.

In many cases, approval is instant. We'll review your request, considering our medical policies, recognized clinical guidelines, and the terms of your benefit plan. Some requests may require additional documentation.

To search for authorization by code, use the Prior Authorization Lookup Tool.

My Insurance Manager

Credit: youtube.com, Insurance Aspects of Case Management

My Insurance Manager is a valuable tool that allows you to manage your insurance needs from the comfort of your own home. You can file claims, get prior authorizations, check eligibility and benefits, and more.

To determine if prior authorization is required for a procedure or durable medical equipment, always check benefits through the voice response unit or My Insurance Manager.

Healthy Blue requires prior authorization for certain procedures and durable medical equipment. This process allows them to check ahead of time whether services meet criteria for coverage by your health plan.

In many cases, approval is instant. When it's not, they'll review your request, considering their medical policies, recognized clinical guidelines, and the terms of your benefit plan.

Some requests may require additional documentation.

Here's a quick rundown of the Prior Authorization Lookup Tool:

  • Search for authorization by code using this tool.
  • They'll review your request based on their medical policies, clinical guidelines, and your benefit plan.

Keep in mind that the review process may take some time, but it's an important step to ensure you receive the coverage you need.

Blue Card (Out-of-Area)

Credit: youtube.com, Health Insurance 101: How Insurance Works In 90 Seconds | BCBSND

Working with out-of-area Blue Cross and Blue Shield (BCBS) members requires some extra steps.

Before providing services to these members, it's essential to check their benefits. You can do this by calling the BlueCard Eligibility Hotline at 800-676-BLUE(2583).

You should also view the out-of-area Blue Plan's medical policy or general prior authorization information.

If you need help with AIM contact information, you can reach them at (800) 859-5299.

The Blue Cross and Blue Shield Association is an association of independent Blue Cross and Blue Shield Plans, and it's registered under the service marks of the Blue Cross and Blue Shield Association.

Here are the key steps to follow when working with out-of-area Blue BCBS members:

  1. Check the member's benefits by calling the BlueCard Eligibility Hotline at 800-676-BLUE(2583).
  2. View the out-of-area Blue Plan's medical policy or general prior authorization information.

Special Programs and Services

Blue Cross Blue Shield (BCBS) offers various special programs and services to support its members. These programs can help with out-of-pocket expenses and improve health outcomes.

The BCBS Chronic Care Management Program helps patients with chronic conditions manage their care and reduce hospital readmissions. This program is available to members with certain chronic conditions, such as diabetes or heart failure.

BCBS also offers the Health Management Program, which provides personalized coaching and support for members with complex health needs. This program can help members manage their conditions and improve their overall health.

Broaden your view: Bcbs Wellness Program

EviCore Program for Medicare

Credit: youtube.com, Specialty Drug Solution | eviCore healthcare

BCBSNM has contracted with eviCore Health (eviCore) to provide certain utilization management prior authorization services for Medicare Members.

EviCore is an independent company that provides specialty medical benefits management for BCBSNM.

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

For a detailed list of CPT codes that apply to these services, check the Prior authorization CPT Code Lists or access the listing on the BCBSNM Medicare eviCore implementation site.

You can obtain prior authorization for these services through 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 eviCore Healthcare Web Portal is available 24x7 and allows you to initiate a case, check status, review guidelines, view authorizations/eligibility, and more after a one-time registration.

You can select the BCBSNM health plan on the eviCore implementation site for the applicable CPT/HCPCS code list and radiation therapy physician worksheets.

AIM Specialty Health Program

Credit: youtube.com, Healthcare Software as Monday Morning Quarterback

The AIM Specialty Health Program is designed to provide certain utilization management prior authorization services for BCBSNM members.

AIM is an independent company that provides specialty medical benefits management for BCBSNM.

Services requiring prior authorization through AIM include Molecular and Genomic Tests, Radiation Therapy, Advanced Imaging, Musculoskeletal, Sleep Studies, and Select Outpatient Procedures.

You can check the CPT Code list in the article to see which outpatient procedures require prior authorization.

The AIM ProviderPortal offers self-service, smart clinical algorithms, and in many instances real-time determinations, which can help increase payment certainty and reduce pre-service decision turnaround times.

To use the AIM ProviderPortal, you'll need to submit a request for prior authorization and respond to post-service review requests.

You can check prior authorization status on the AIM ProviderPortal, which is a convenient feature for providers.

Here are some benefits of using the AIM ProviderPortal:

  • Medical records for pre or post-service reviews are not necessary unless specifically requested by AIM.
  • AIM's ProviderPortal offers self-service, smart clinical algorithms and in many instances real-time determinations.
  • Check prior authorization status on the AIM ProviderPortal.
  • Increase payment certainty.
  • Faster pre-service decision turnaround times than post service reviews.

Providers can use the AIM ProviderPortal to submit the New Mexico Uniform Prior Authorization Form for services requiring prior authorization by AIM.

The 2022 Specialty Pharmacy Infusion Site of Care Benefit Preauthorization Drug List is effective as of April 1, 2022, and can be found on the AIM ProviderPortal.

Frequently Asked Questions

Why is it so hard to get a prior authorization?

Prior authorization delays often stem from errors in patient information, insurance details, or incorrect paperwork. Ensuring accurate and up-to-date information can help streamline the process.

What is the phone number for BCBS Texas prior authorization?

For BCBS Texas prior authorization, call 800-528-7264 or the phone number listed on the back of your ID card. You can also reach out to the number listed on the back of your ID card for assistance.

How do I submit a prior authorization to BCBS SC?

To submit a prior authorization to BCBS SC, call our dedicated line at 855-843-2325 or fax to 803-264-6552. Our team will guide you through the process and ensure a smooth submission.

What is the process for preauthorization for a patient?

To get preauthorization for a patient, the healthcare provider must first check the health plan's policy to see if it's required, then sign a request form to verify medical necessity. This process ensures that the prescribed treatment meets the plan's requirements.

Victoria Funk

Victoria Funk

Junior Writer

Victoria Funk is a talented writer with a keen eye for investigative journalism. With a passion for uncovering the truth, she has made a name for herself in the industry by tackling complex and often overlooked topics. Her in-depth articles on "Banking Scandals" have sparked important conversations and shed light on the need for greater financial transparency.

Love What You Read? Stay Updated!

Join our community for insights, tips, and more.