bcbs prompt pa Prior Authorization and Appeals Process Explained

Understanding the Prior Authorization and Appeals Process can be overwhelming, but it's essential to navigate the system effectively.

Prior authorization is required for certain treatments or services, which can delay care and add complexity to the process.

BCBS of Prompton PA has a specific process for prior authorization, which includes submitting a request through their online portal or by contacting their customer service.

The request must include detailed information about the treatment or service, including the diagnosis, treatment plan, and any relevant medical records.

A decision on the prior authorization request will typically be made within 24-48 hours, but can take up to 3 business days in some cases.

If a prior authorization request is denied, you can appeal the decision by submitting a written appeal within 180 days of the denial.

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The prior authorization process can be a bit tricky, but don't worry, I've got the lowdown.

You can submit prior authorization requests 24/7 at Availity.com for all lines of business. Some medicines and benefits require prior authorization by Blue Cross Complete.

To submit a prior authorization request, you can use the Utilization management authorization request form (PDF) or submit electronically through your Electronic Health Record tool software or online portals.

Some medicines require prior authorization, and you can find a list of codes that require prior authorization by clicking the HCPCS PA List (PDF).

You must submit a request for a prior authorization for your patient, and you can also submit an override of a drug restriction. Request from pharmacies aren't accepted.

You can submit authorizations electronically through the Medical Authorizations portal, accessed through NaviNet located on the Workflows menu.

Here are the benefits of submitting authorizations electronically:

Effective May 1, 2022, Blue Cross Complete will require prior authorization from Evolent, formerly National Imaging Associates, Inc., for most non-emergency outpatient diagnostic imaging services. You can find more information on the Medical Specialty Solutions Utilization Review Matrix 2022 (PDF).

If you're not satisfied with the initial denial of your claim, you can request special approval through BCBS. This process allows you to appeal the decision and potentially receive coverage for your services.

The special approval process typically takes 30 days to complete, but it can be expedited in urgent cases. In some cases, coverage may be granted retroactively, meaning you can receive reimbursement for services already received.

To request special approval, you'll need to submit a written appeal to BCBS, including specific details about your medical condition and treatment plan.

Non-emergent air transport requires prior authorization, which can be obtained by calling Alacura directly at 1-877-561-2287 or faxing to 1-877-561-4664.

To verify benefits and request prior authorization for certain medical services, you can visit Availity.com, call 1-800-924-7141, or fax to 1-866-558-0789. These services include CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET, and CPT.

Prior authorization is also required for musculoskeletal services, including spinal surgery, joint surgery (hip, knee, and shoulder), and pain management. You can request prior authorization at Availity.com or by faxing to 1-866-747-0587.

Sleep studies performed in a lab setting for adults 18 years or older require prior authorization, which can be obtained at Availity.com or by faxing to 1-866-558-0789.

The following services require prior authorization:

Note: The specific requirements for prior authorization may vary depending on the service and the individual's insurance coverage.

If you disagree with a decision made about your patient's care, you can request a Peer-to-Peer discussion with a doctor to review the details of their condition and care options.

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

You have 18 months to submit a Provider Reconsideration Form to request additional information that may affect the decision.

The reconsideration process is outlined in a helpful guide with timelines for each line of business.

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To get started with precertification and authorization, you'll need to understand the process. 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.

You can submit a precertification request through the secure pre-certification section, or by calling 800-782-4437 for inpatient medical stays or 800-952-5906 for inpatient mental health stays.

To view the status of an existing request, you'll need to visit the secure pre-certification section. Members of some group health plans may have terms of coverage or benefits that differ from the information presented here, so it's always a good idea to verify coverage or benefits by calling 800-676-BLUE.

Precertification is not required for out-of-area members, but you can still view the out-of-area Blue Plan's general precertification/authorization information by entering the first three letters of the member's identification number on the Blue Cross Blue Shield ID card and clicking "GO".

Here are the phone numbers you'll need to remember:

By following these steps and remembering these phone numbers, you'll be well on your way to navigating the precertification and authorization process with ease.

Blue Cross Blue Shield (BCBS) is a trusted health insurance provider. They offer a range of plans, including the Prompt PA plan.

BCBS has a network of over 90,000 healthcare providers in Pennsylvania, making it easy to find a doctor or specialist.

The Prompt PA plan is available to individuals, families, and small businesses. It offers a variety of coverage options, including medical, dental, and vision care.

You can enroll in the Prompt PA plan through the Health Insurance Marketplace or directly with BCBS. The open enrollment period typically runs from November to December each year.

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

The prior authorization requests are reviewed based on the existence of coverage and the appropriateness of care. This ensures that patients receive quality and cost-effective healthcare services.

You can also use the Prior Authorization Lookup Tool to find out if a service needs prior authorization. Simply type in a CPT or HCPCS code to get started.

Prior authorization is required for certain medicines and benefits, such as healthcare common procedure coding system medications. These require a prior authorization request using the Medication Prior Authorization Request Form or an electronic Prior Authorization through your Electronic Health Record tool software.

You must submit a request for a prior authorization for your patient, and you must also submit an override of a drug restriction. Request from pharmacies aren't accepted.

Here are the steps to submit authorizations electronically:

A prior authorization for healthcare common procedure coding system medications is required before they are covered by Blue Cross Complete. You can find a list of codes that require prior authorization by clicking the HCPCS PA List (PDF).