Does BCBS Require Prior Authorization for Medical Services

BCBS requires prior authorization for certain medical services, but it's not a one-size-fits-all approach. The company has a list of services that require prior authorization, including some surgeries, tests, and medications.

Some of the services that require prior authorization include certain procedures like knee replacements, hip replacements, and spinal surgeries. These services are typically subject to a review process to ensure they're medically necessary.

BCBS also requires prior authorization for some medications, especially those that are considered high-cost or high-risk. This includes some medications for chronic conditions like diabetes, asthma, and rheumatoid arthritis.

BCBS will review each case individually to determine if prior authorization is required, and the decision is based on a variety of factors, including the patient's medical history and the recommended treatment plan.

Precertification is a process that involves a prior authorization review as required by BCBSKS 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.

To submit a request or view the status of an existing request, you can visit the secure pre-certification section. This is a crucial step in ensuring that your inpatient medical stays are properly reviewed and approved.

Inpatient medical stays and mental health stays require precertification, and you can submit requests through Availity or by calling 800-782-4437 for medical stays and 800-952-5906 for mental health stays.

Precertification helps control the risk of fraud and inappropriate use, ultimately keeping the cost of health care premiums affordable for everyone.

Here are the details on how to submit a request or view the status of an existing request:

Remember, precertification is a requirement for inpatient admissions, and it's essential to follow the proper procedures to ensure your requests are properly reviewed and approved.

In BCBSKS, a Pre-Service Claim is a request for a claim's decision when Prior Authorization of the services is required. These are defined in the member contract and on the website under precertification/prior authorization.

Pre-Service Requests are a courtesy review performed by BCBSKS, which includes requests for services, supplies, or prescription drugs that have a medical policy, are high-cost, or could be deemed experimental/non-covered based on the member's contract. If the service is being performed inpatient, prior authorization is required.

Prior Authorization is required for certain procedures, services, and medications, as well as for all inpatient admissions, and the requirements and processes for authorization differ based on the patient's coverage plans.

Pre-Service Claim refers to a request for a claim's decision when Prior Authorization of the services is required by BCBSKS.

Pre-Service Requests are a courtesy review performed by BCBSKS, and they're used to determine coverage for services, supplies, or prescription drugs that have a medical policy, are high-cost, or could be deemed experimental/investigation.

These requests are optional, but they can help you understand if a service will be covered before you receive it.

BCBSKS requires Prior Authorization for inpatient services, but not for pre-service requests.

Many pharmacy medical policies are now maintained through Prime Therapeutics, the pharmacy benefit manager.

If you're trying to navigate the healthcare system, understanding the contract is crucial. You'll need to know what's required for precertification and authorization.

Precertification is the process of getting prior approval for certain medical services. This includes inpatient admissions, unless it's an emergency or for obstetrical care.

To precertify, you'll need to contact the relevant number: 800-782-4437 for inpatient medical stays or 800-952-5906 for inpatient mental health stays.

You can also submit a request or view the status of an existing request online. However, you'll need a secure login with Availity to do so.

It's essential to verify coverage or benefits before seeking medical services. You can call 800-676-BLUE or send an electronic inquiry through your local Blue Plan for more information.

Some group health plans may have different terms of coverage or benefits. Be sure to check with your plan to understand what's covered and what's not.

Here's a quick reference guide to the numbers you may need:

Precertification is a crucial step in the healthcare process, and BCBS requires it for various services. BCBSKS requires precertification for all inpatient medical stays, which can be done through a secure login with Availity or by calling 800-782-4437.

Some services require special approval, such as non-emergent air transport, which needs prior authorization from Alacura. You can also verify benefits and request prior authorization at Availity.com or by calling 1-800-924-7141.

Radiological services like CT, MRI, and PET scans require prior authorization, as do hip surgeries, including total hip arthroplasty and revision/conversion hip arthroplasty. These services should be approved in advance to ensure coverage.

Here are some services that require prior authorization:

If you're unsure about which services require prior authorization, you can check with your provider or contact BCBS directly. They can help you determine what's needed and provide guidance on the process.

Precertification is a prior authorization review required by BCBSKS for inpatient admissions, unless it's for a medical emergency, life-threatening condition, obstetrical care, or outside the 50 United States.

You can submit a request or view the status of an existing request by visiting the secure pre-certification section, which requires a secure login with Availity. You can also call 800-782-4437 for inpatient medical stays or 800-952-5906 for inpatient mental health stays.

For some group health plans, terms of coverage or benefits may differ from the general policies of BCBSKS. To verify coverage or benefits, call 800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.

To submit a precertification request, you can use Availity.com, call 1-800-924-7141, or fax to 1-866-558-0789. This is required for services such as CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET, and CPT.

Here are the contact details for precertification:

Please note that precertification is not a guarantee of payment, and you should verify coverage or benefits with BCBSKS directly.