BlueCross BlueShield of Tennessee Prior Authorization Form: A Step-by-Step Guide

Understanding BlueCross BlueShield of Tennessee Prior Authorization

Prior authorization through BlueCross BlueShield of Tennessee (BCBST) is a critical healthcare administrative process that ensures medical services, procedures, and medications meet medical necessity requirements before treatment begins. This preservice utilization management review protects both patients and providers by confirming coverage eligibility and preventing unnecessary costs.

The BlueCross BlueShield of Tennessee prior authorization form is a crucial component of the healthcare delivery process, ensuring that services rendered are both clinically appropriate and cost-effective. Healthcare providers must navigate this system effectively to secure timely approvals and maintain practice revenue streams while ensuring optimal patient care delivery.

Important Program Changes for 2025

Healthcare providers working with BCBST need to be aware of significant changes affecting prior authorization processes in 2025. As of 9/1/24, EviCore will no longer manage prior authorization for Commercial Membership of Blue Cross Blue Shield of Tennessee. Additionally, Effective 2/1/25, EviCore will cease processing for Blue Cross Blue Shield of Tennessee Radiology and Cardiology prior authorization requests for Medicaid members.

These changes mean providers must now submit authorization requests directly through BCBST's systems rather than through EviCore for most services, requiring updates to existing workflows and submission processes.

Step-by-Step Prior Authorization Process

Step 1: Download the Prior Authorization Form

The prior authorization form can be obtained through multiple channels:

Primary Access Points:

• BCBST Provider Portal at provider.bcbst.com
• Provider Documents and Forms section on the official BCBST website
• Direct contact with BCBST Provider Services
• Availity is our secure provider portal, which makes it easy for you to do business with us

Important Note: Always ensure you're using the most current version of the form, as outdated forms may lead to processing delays or denials. The forms in this online library are updated frequently—check often to ensure you are using the most current versions.

Step 2: Gather Required Patient Information

Before completing the form, collect all necessary patient information:

Essential Patient Details:

• Full legal name (as it appears on insurance card)
• Date of birth
• Member ID number
• Social Security Number (if required)
• Contact information (address, phone number)
• Primary care physician information
• Referring physician details (if applicable)

Pro Tip: Accurate patient details are essential for ensuring approval. Double-check all information against the patient's insurance card to prevent processing delays.

Step 3: Complete Provider Information Section

This section demands precise details about the healthcare provider requesting the prior authorization. Ensure that the provider's NPI and contact information are correctly documented. Include the following provider details:

• Healthcare provider's full name
• National Provider Identifier (NPI) number
• Practice or facility name
• Complete address and contact information
• Specialty designation
• DEA number (if applicable for controlled substances)

Step 4: Specify the Requested Service or Medication

Here, provide a thorough description of the requested service. Include all relevant procedure codes (CPT/HCPCS) and, if applicable, the anticipated number of treatments or sessions.

Required Service Information:

• Detailed description of requested treatment or service
• Appropriate CPT, HCPCS, or NDC codes
• ICD-10 diagnosis codes supporting medical necessity
• Frequency and duration of treatment
• Anticipated start date
• Place of service designation

Step 5: Provide Clinical Justification

The clinical justification section is crucial for approval success. Include comprehensive documentation that demonstrates medical necessity:

Essential Supporting Documentation:

• Relevant medical history and previous treatments attempted
• Current symptoms and clinical findings
• Laboratory results and diagnostic reports
• Treatment plans and expected outcomes
• Clinical guidelines or evidence-based research supporting the request
• Documentation of failed alternative treatments (if applicable)

Step 6: Submit the Completed Form

BCBST accepts prior authorization submissions through multiple channels. Choose the method that best fits your urgency and workflow needs:

Common Reasons for Prior Authorization Denials

Understanding frequent denial reasons helps providers prepare stronger initial submissions and avoid unnecessary delays.

Documentation Deficiencies

Incomplete or insufficient clinical documentation represents the most frequent cause of prior authorization denials. Common documentation issues include:

• Missing required fields on the authorization form
• Insufficient clinical notes supporting medical necessity
• Outdated or irrelevant supporting documentation
• Illegible handwritten information

Medical Necessity Issues

Requests may be denied when clinical evidence fails to support the medical necessity of the proposed service according to BCBST's coverage guidelines and medical policies. Ensure your request aligns with:

• Current clinical practice guidelines
• BCBST's specific medical policies
• Evidence-based treatment protocols
• Appropriate step therapy requirements

Incorrect Coding

Using incorrect CPT codes, diagnosis codes, or modifier codes can result in automatic denials. Common coding errors include:

• Mismatched diagnosis and procedure codes
• Using outdated or deleted codes
• Incorrect modifier usage
• Missing required secondary diagnosis codes

Alternative Treatment Options

BCBST may deny requests when less costly, equally effective treatment alternatives are available and haven't been attempted or considered. Document previous treatments tried and reasons for their failure or inappropriateness.

Best Practices for Successful Submissions

Implementing these proven strategies significantly improves prior authorization approval rates and reduces processing times.

Maintain Accurate Patient Information

Double-check all patient demographic information against the insurance card to prevent processing delays caused by data mismatches. Even minor discrepancies in member ID numbers or dates of birth can result in system rejections.

Submit Complete Documentation

Provide comprehensive clinical documentation that tells a complete story about the patient's condition and treatment needs. Include:

• Detailed medical history relevant to the request
• Current diagnostic results and clinical findings
• Clear treatment plans with measurable goals
• Documentation of medical necessity aligned with coverage policies

Follow Up Proactively

Monitor authorization status regularly and respond promptly to any requests for additional information. Timely responses prevent authorization expirations and treatment delays. Establish systematic follow-up procedures:

• Check status within 48-72 hours of submission
• Respond to additional information requests within 24 hours
• Maintain communication logs for audit purposes

Understand Plan-Specific Requirements

Different BCBST plans may have varying prior authorization requirements. Familiarize yourself with specific plan guidelines by:

• Reviewing plan-specific formularies and coverage policies
• Understanding benefit limitations and exclusions
• Staying updated on policy changes and updates
• Participating in BCBST provider education sessions

Conclusion

Successfully navigating the BlueCross BlueShield of Tennessee prior authorization process requires understanding current requirements, proper form completion, and efficient submission processes. With BCBST's commitment to reducing authorization requirements and improving processing times, the landscape continues evolving toward more provider-friendly systems.

By following this comprehensive guide, healthcare providers can improve their prior authorization approval rates, reduce administrative burden, and ensure timely patient care delivery. Remember to verify current requirements through official BCBST channels, as policies and procedures may change based on market conditions and regulatory requirements.

Effective prior authorization management ultimately benefits all stakeholders by ensuring appropriate resource utilization, maintaining care quality standards, and supporting sustainable healthcare delivery systems. Stay informed about program updates and leverage available technology solutions to optimize your prior authorization workflow.

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Frequently Asked Questions (FAQs)

1. How long does BCBST take to process prior authorization requests?

‍Processing times vary by submission method: electronic submissions through Availity typically receive decisions within 24-72 hours, while paper submissions can take 7-14 business days. Urgent medical requests may receive expedited review within 24 hours.

2. What happens if I don't get prior authorization before providing services?

‍If required prior authorization isn't obtained, the service may not be covered, and the provider may be responsible for costs. For certain government plans, BCBST won't reimburse providers, and members cannot be billed for non-authorized services.

3. Can I submit prior authorization requests after hours or on weekends?

‍Yes, electronic submissions through Availity are available 24/7. However, review and processing occur during standard business hours. Phone submissions are only available during Provider Services hours.

4. Do emergency services require prior authorization?

‍No, emergency services are exempt from prior authorization requirements. Emergency and life-threatening conditions receive priority handling, though documentation may still be required for billing purposes.

5. What should I do if my prior authorization request is denied?

‍If denied, review the denial reason carefully, gather additional supporting documentation if needed, and consider submitting an appeal or peer-to-peer review request. BCBST provides appeal processes for disputed decisions.