How Long Does Prior Authorization Take Blue Cross Blue Shield

Blue Cross Blue Shield's prior authorization process can be a mystery to many. Typically, it takes around 2-3 business days for Blue Cross Blue Shield to review and process a prior authorization request.

The exact timeframe can vary depending on the complexity of the request and the workload of the insurance provider. On average, 85% of prior authorization requests are processed within 2-3 business days.

Some requests may take longer, up to 10 business days or more, especially if additional information is required from the patient's doctor or other healthcare providers.

Prior authorization is a process that helps ensure certain medications and medical services are safe and necessary for your care. Your doctor or provider usually makes this request for you.

Certain medications and medical services need to be approved by Blue Shield of California before they will be covered. This is called a prior authorization.

Without this pre-approval, Blue Shield may not help pay for your medication or medical service, and you will have to pay out of pocket.

Prior authorization is needed for certain medications and medical services that need to be approved by Blue Shield before they will be covered.

These services often require pre-approval to ensure they are safe and necessary for your care. Your doctor or provider usually makes this request for you.

Without pre-approval, Blue Shield may not help pay for your medication or medical service, and you will have to pay out of pocket.

Prior authorization can be a bit of a hassle, but it's there to ensure you're getting the right care.

Some services require prior authorization before they can be covered by your Blue Cross Blue Shield plan. This includes radiological services like CT scans, MRIs, and PET scans. Your doctor will need to consult with the insurance company's medical team to get approval for these services.

Cardiology services also require prior authorization, including echocardiography, diagnostic coronary angiography, and Percutaneous Coronary Intervention (PCI). This helps ensure that you're getting the right treatment for your heart health.

Hip surgeries, including total hip arthroplasty and revision/conversion hip arthroplasty, require prior authorization as well. This is to ensure that you're getting the best possible care for your hip health.

Here are some specific services that require prior authorization:

These services are subject to change, so it's always a good idea to check with your insurance company to confirm what services require prior authorization.

To get started with prior authorization, you'll need to check if the service requires it through the Availity Provider Portal or your preferred web vendor. This will help you confirm coverage and other important details.

If prior authorization is required, you can use the AIM ProviderPortal to request it. AIM is an independent company that provides specialty medical benefits management for BCBSNM. You can also use the AIM ProviderPortal to respond to post-service review requests by AIM.

To use the AIM ProviderPortal, you'll need to submit a request for prior authorization, which may or may not require medical records. The portal offers self-service, smart clinical algorithms, and in many instances real-time determinations.

Utilization Management Program is an essential part of healthcare management, and it's crucial to understand how it works. Utilization Management includes prior authorization, recommended clinical review, and post-service review to determine if a service is covered under the health plan.

The UM Program description defines the structure of the UM program for BCBSMT, promoting member and provider satisfaction through coverage and access to affordable, quality health care. UM Prior Authorization, Recommended Clinical Review, and post-service reviews are completed using evidence-based guidelines.

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. Prior authorization requirements for Blue Cross Medicare Advantage members include services such as molecular and genomic tests, musculoskeletal, outpatient advanced radiology, and more.

To obtain prior authorization through eviCore, providers can use the eviCore Healthcare Web Portal or call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday. The Web Portal is available 24x7 and allows providers to initiate a case, check status, review guidelines, view authorizations/eligibility, and more.

BCBSNM has also contracted with AIM Specialty Health (AIM) to provide certain utilization management prior authorization services for certain Commercial, Retail, and ASO members and Blue Cross Community Centennial Members. AIM provides specialty medical benefits management for BCBSNM. Services requiring prior authorization through AIM include molecular and genomic tests, radiation therapy, advanced imaging, and more.

To use the AIM ProviderPortal for pre & post-service reviews, providers can request prior authorization and respond to post-service review requests by AIM. Medical records may or may not be needed for pre or post-service reviews using the AIM portal due to the smart clinical algorithms within the portal. Benefits of using the AIM ProviderPortal include medical records not being necessary unless specifically requested by AIM, self-service, smart clinical algorithms, and real-time determinations.

Here are the services requiring prior authorization through AIM and eviCore:

Remember to check eligibility and benefits first through the Availity Provider Portal or your preferred web vendor before rendering services. This will help you confirm coverage and other important details, such as prior authorization requirements and vendors, if applicable.

Getting started with prior authorization can be overwhelming, but breaking it down into manageable steps can make the process much smoother.

First, identify the type of prior authorization required, as this will determine the necessary documentation and approval process.

Next, gather all required documentation, including medical records, test results, and treatment plans.

Prioritize and organize the documentation to ensure it's easily accessible and reviewable.

Consult with healthcare providers and payers to confirm the specific requirements for each case.

Establish a system for tracking and managing prior authorization requests to stay on top of the process.

Check First! Medical Services can be a bit of a hassle, but it's worth it to avoid unnecessary costs. Florida Blue health coverage requires prior authorization for certain services to ensure you're getting the right care.

Your doctor needs to consult with Florida Blue's medical and pharmacy teams before providing services like radiological services, cardiology services, and hip surgeries. This includes procedures like CT scans, MRIs, and echocardiography.

Some examples of services that require prior authorization include:

This is not an exhaustive list, so it's best to check with Florida Blue directly for the most up-to-date information.

Before you schedule a medical service, it's a good idea to check if it's covered by your insurance. This is where predetermination comes in.

A predetermination is a written request to assess benefits and medical necessity prior to rendering services. It's elective for certain services not subject to prior authorization.

To submit a predetermination, you can use Availity's Attachments tool to submit electronic requests or fax the Predetermination Request Form along with supporting documentation. Don't forget to fill out the entire form, including procedure code(s) and diagnosis code(s).

If you're submitting a major diagnostic test, be sure to include the patient's history, physical, and any prior testing information. You may also need to include original photos or digital color copies of the affected area.

Here are the ways to submit a predetermination:

Keep in mind that predetermination does not guarantee payment. All payments are subject to determination of the insured person's eligibility and other provisions of the policy at the time services are rendered.

If you're a Blue Shield member, you can check if a medical service needs prior authorization by opening the Blue Shield prior authorization list.

Some services require prior authorization, including advanced imaging/radiology, molecular genetic lab testing, and musculoskeletal procedures. You can also call Customer Service at the number on your Blue Shield member ID card for any coverage questions.

Outpatient services that may require prior authorization include sleep services for ASO members with AIM, and select outpatient services including but not limited to those listed by BCBSNM.

Prior authorization is required for services like radiological services, cardiology services, and hip surgeries. Your doctor will need to consult with Blue Shield's medical and pharmacy teams before these services are provided.

To submit a prior authorization request, you can use the authorization form on the Blue Shield website or call (800) 535-9481.

If you're a healthcare provider working with Blue Cross Medicare Advantage, you'll want to familiarize yourself with the eviCore Program. This program is designed to streamline the prior authorization process for certain medical services.

eviCore is an independent company that provides specialty medical benefits management for BCBSNM. They've partnered with BCBSNM to provide prior authorization services for Medicare members.

To access the eviCore implementation site, select the BCBSNM health plan for the applicable CPT/HCPCS code list and radiation therapy physician worksheets. This will give you the information you need to navigate the program.

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

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

You can obtain prior authorization for these services through the eviCore Healthcare Web Portal, available 24x7, or by calling toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.