What is Prior Authorization with Blue Cross Blue Shield?

Prior authorization (PA) is a common requirement for many drugs and procedures, and it often causes delays in patient care. Although insurers, like Blue Cross Blue Shield, require prior authorization (PA) for many drugs and procedures, it adds administrative burdens to your patient care. According to the American Medical Association (AMA), 94% of physicians say PA requirements cause delays. When working with Blue Cross Blue Shield (BCBS), these delays can interfere with your treatment plans, making it more difficult to offer timely care. 

PA is a common requirement among health insurers, including BCBS, for certain medical services, procedures, and medications. This process mandates that you obtain approval from BCBS before delivering specific treatments to ensure they meet the insurer's medical necessity criteria.

To aid the PA process, BCBS offers several tools and resources. For instance, you can use the Availity portal to check eligibility, submit PA requests, and track the status of existing requests.

In this blog, we'll explore the specifics of the PA process with BCBS, including how to determine when PA is required, the steps involved in submitting a request, and strategies to streamline the process for better patient care outcomes..

Understanding Prior Authorization with Blue Cross Blue Shield

Prior authorization, also called pre-authorization or pre-certification, is a process used by Blue Cross Blue Shield (BCBS) to check if a medical service, prescription, or supply is covered by a member’s health plan. This process makes sure that the service is medically necessary and follows the plan's rules before it is provided.

You, as a physical therapist also need to handle PA when treating patients requiring intensive or prolonged therapy. After reviewing the proposed treatment plan, insurance companies may approve it based on their policies.

Why Prior-Approval Is Necessary?

Without approval, your patients may face significant out-of-pocket expenses associated with treatments and medications. This means you must manage the administrative burden of addressing denials or educating your patients about cost disparities.

When insurers reject PA requests or take longer than expected to approve them, patients experience disruptions in their treatment plans. This can negatively impact their recovery and overall health. For instance, delays in physical therapy sessions can extend recovery times and increase the risk of complications.

Spry automates submissions, drastically reduces manual labor with 30-40% faster note-creation, and minimizes errors. By using Spry, you can increase approval rates and save the time spent obtaining prior authorization.

What is the Process of Prior Authorization with Blue Cross Blue Shield?

The process for requesting prior authorization can vary depending on the BCBS plan and the type of service. Generally, you are responsible for starting the prior authorization request. Here are the typical steps:

1. Verify Coverage

Before submitting a prior authorization request, check if the service requires approval by confirming your patient's eligibility and benefits. This can be done using the BCBS provider portal or by calling the customer service number on your patient's ID card.

2. Gather Necessary Information

Make sure to have all the required information ready, such as:

• The patient's medical condition
• The proposed treatment plan
• The date of service and how long the treatment will take (if needed)
• Patient’s ID, name, and date of birth
• The place where the treatment will occur
• The provider's name, address, and National Provider Identifier (NPI)
• Diagnosis and procedure codes

3. Submit the Request

Depending on the BCBS plan, the request can be submitted in one of the following ways:

• Online: Through the BCBS provider portal or using electronic transactions (e.g., HIPAA-standard 278).
• By Phone: Call the BCBS provider services number.
• By Fax: Send the completed forms and documentation to the fax number provided.

4. Await Decision

After submitting, the request will be reviewed to see if the service meets the plan’s medical necessity guidelines. You will be notified of the decision, which could include approval, denial, or a request for more information.

For specific information related to your BCBS plan, refer to the provider manual or contact the customer service number on the member's ID card.​

By automating requests and minimizing manual submission efforts, Spry streamlines the PA process. Spry ensures that providers have the required paperwork for faster approvals and accelerates PA timelines. Spry improves claim accuracy, reducing denial rates, which boosts the overall effectiveness of the PA process.

After submitting a prior authorization request to Blue Cross Blue Shield (BCBS), it's important to keep track of its status to make sure the process is moving along and there are no delays in your patient care.

How to Track Blue Cross Blue Shield Prior Authorization Status?

BCBS offers several ways for you, healthcare providers and members to check the status of their requests.

For PTs and Providers

Providers and PTs can track the status of prior authorization requests using the following methods:

1. Electronic Provider Access (EPA) Tool

This secure online platform lets you submit and track prior authorization requests. It's available for different BCBS plans, including BCBS of Massachusetts.

2. Authorization Manager

This tool is used for inpatient and outpatient medical and behavioral health authorization requests. You can check their request status here.

3. Carelon and eviCore Portals

For certain services like genetic tests, high-tech radiology, outpatient cancer care, and sleep management, you can use the Carelon portal. For other services, eviCore's portal might be the one to use.

4. Phone Support

You can call BCBS customer service at 1-800-676-BLUE to ask about the status of their request.

For Members

Members can also check the status of their prior authorization requests using these methods:

1. MyBlue Member Portal

By logging into the MyBlue portal, members can go to the 'Benefits' section and select 'Authorization Status' to see the current status of their requests.

2. Mobile App

The MyBlue mobile app allows members to check the status of their prior authorization requests from anywhere.

3. Customer Service

Members can call the number on the back of their BCBS member ID card to speak with a representative and get updates on the status of their requests.

It's important to remember that the information provided is based on the current date and time and might not be updated in real-time. Also, getting prior authorization does not guarantee payment, as claims still need to be verified for eligibility and benefits when the service is provided.

By using these resources, both you and members can stay informed about the status of prior authorization requests, ensuring that care is provided promptly and appropriately.

What are the Consequences and Solutions of Missing Prior Authorization with Blue Cross Blue Shield?

Not getting prior authorization for services covered under Blue Cross Blue Shield (BCBS) plans can cause serious problems for both you, and your patients.

Consequences of Missing Prior Authorization

The consequences of missing prior authorization with Blue Cross Blue Shield are as follows:

1. Claim Denials

If services are provided without the necessary prior authorization, they are often denied by the insurer. For example, about 9% of in-network claims are denied due to missing prior authorization or referral.

2. Financial Impacts

You may struggle financially because they can't bill the insurer for unauthorized services, potentially leading to lost income.

Solutions to Address Missing Prior Authorization

The solutions of missing prior authorization with Blue Cross Blue Shield are as follows:

1. Appeal the Denial

You can challenge the denial by submitting a formal appeal to BCBS, providing additional documentation to show the medical need for the service. It's important to follow BCBS's appeal process and deadlines to improve the chances of approval.

2. Submit a Retroactive Authorization Request

In some cases, BCBS may allow a retroactive authorization request. Providers and PTs should reach out to BCBS right away to ask if this option is available and learn how to submit a request.

3. Improve Authorization Processes

To prevent future issues, you can set up stronger internal procedures to check prior authorization requirements before offering services. Using BCBS’s provider portal and keeping up with policy changes can help avoid mistakes.

By carefully managing prior authorization requirements and addressing any issues quickly, you can reduce the negative impacts of missing prior authorization and continue offering quality care to your patients.

Conclusion

Understanding how long prior authorization takes Blue Cross Blue Shield is necessary for you to ensure that medications and treatments are approved promptly without unnecessary delays or denials.

By checking if prior authorization is needed, gathering the required documents, and using tools like the Authorization Lookup Tool, you can make the process smoother and reduce delays. If issues come up, solutions like submitting retroactive requests, appealing denials, and improving internal processes can help. Taking a proactive approach to BCBS prior authorization ensures that providers stay compliant and helps provide better care for your patients.

By using automation, Spry ensures timely patient care by reducing errors and cutting manual pre-authorization submission time by 60%. Spry’s comprehensive approach has improved healthcare providers' and PTs’ operational efficiency and financial performance by reducing accounts receivable days by 40% and increasing claim approval rates to over 98%. Schedule a demo with Spry today.