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PAP241

Prior Authorization Requirements


Provider Administrative Policy

Section
General Billing
Policy Date
February 2008
Status/Date
Revised/June 2014
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Prior Authorization Requirements

Connected Care referrals
For Connected Care members, primary care physicians (PCP) are required to submit a referral when referring a patient to an in-network contracting provider. If the services are not available in-network, all referrals to an out-of-network, non-contracting provider require prior authorization by Blue Cross of Idaho. You must submit the request online, fax or mail out-of-network referral requests and supportive clinical documentation or medical records to:

Fax: 208-331-7344
Mail:

Blue Cross of Idaho
Attn: Medical Review Department
PO Box 7408
Boise, ID 83707
Confidential Request

 

For Behavioral Health prior authorizations refer to PAP902.

Please see below for more information regarding online authorization submission.

 

Service Requests

Prior authorization
Prior authorization is the process of determining the medical necessity of elective inpatient admissions and selected outpatient procedures, surgeries, services or drugs categorized as one of the following:

  • High utilization
  • High cost
  • Potentially cosmetic
  • Investigational or experimental in nature

We perform prior authorization on a prospective basis to gather the clinical information necessary to determine if the services requested are eligible for coverage under the member's benefit plan. The process involves working with providers to obtain the necessary medical records and treatment plan to determine medical necessity for the planned services.

Please submit all elective prior authorization requests at least 10 days prior to the scheduled date of service. If the service is urgent, please note the reason for the urgent request. We will respond to urgent requests within 72 hours. 

Definition of urgent care:

Urgent care is any request for medical care or treatment with respect to which the application of the time periods for making nonurgent care determination could result in the following circumstances:

  • Could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, based on a prudent layperson's judgment, or
  • In the opinion of a practitioner with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

Certain Blue Cross of Idaho groups may not require prior authorization for listed services on this policy. Please verify prior authorization or medical necessity review requirements on the eligibility section of the Web site or contact customer service.

Prior authorizations when Blue Cross of Idaho is secondary
Prior authorization is not required when Blue Cross of Idaho is the provider of secondary coverage. If the primary carrier denies the charges, Blue Cross of Idaho requires a post-service review if there is no authorization on file. All services, whether primary or secondary, may be subject to medical necessity review. 

Prior Authorization Form  (includes list of services requiring prior authorization)

Online:

  • Go to: bcidaho.com
  • Select Providers
  • Log on using your username and password
  • Select Authorizations/Notifications
  • Select Click to Access Authorization/Notifications under Authorization/Notifications

If you need training or assistance with the provider portal for submission of online authorizations, please contact your Provider Relations Representative (see PAP100).

Fax: 208-331-7344
Mail:

Blue Cross of Idaho
Attn: Medical Review Department
PO Box 7408
Boise, ID 83707
Confidential Request

 

Pharmacy Requests

Pharmacy prior authorization
A list of medications requiring prior authorization is available on the Blue Cross of Idaho website at
bcidaho.com.

  • Select Providers
  • Log in and select Prescription Drugs
  • Select Drugs Requiring Prior Authorization

The ordering physician needs to request the prior authorization (see link below) by faxing or mailing the following information to Blue Cross of Idaho:

  • Completed prior authorization request form
  • All medical records documenting the clinical indications and/or medical necessity
  • Mark “Urgent Request” if the determination is urgent. Please understand that we only honor urgent requests if the documentation supports that the determination of urgent care as defined above.

Pharmacy Prior Authorization Form

Online:

  • Go to:  bcidaho.com
  • Select Providers
  • Log on using your username and password
  • Select Authorizations/Notifications
  • Select Click to Access Authorizations/Notifications under Authorizations/Notifications

Fax: 208-387-6969

Mail:

Blue Cross of Idaho
Attn: Pharmacy Management Department
PO Box 7408
Boise, ID 83707
Confidential Prior Authorization Request

Blue Cross will notify the requestor with the prior authorization determination within 10 business days of receiving the completed non-urgent request or 72 hours for urgent requests.

A completed form submitted with supportive clinical and diagnostic medical records will help us expedite the review process. Additional forms are available on the Blue Cross of Idaho website at bcidaho.com.

For emergency services, please notify Blue Cross within 24 hours about services that typically require prior authorization.

Beginning September 1, 2014 revised provider reconsideration language: 

Provider reconsideration of prior authorization denials.

Blue Cross of Idaho offers providers a reconsideration review of a prior authorization denial for insufficient information to determine medical necessity. The denial letter will describe the information needed to complete the medical necessity review. Authorizations that are denied as not medically necessary or investigational based on medical policy will not be eligible for reconsideration but can be appealed through the member appeal process. A provider cannot exercise appeal rights on behalf of the member without the member's express written authorization. Our determination of the provider's request for reconsideration does not affect the member's appeal rights under his or her policy.

Blue Cross of Idaho does not offer reconsiderations for services or procedures excluded under the member contract.

Reconsideration

If a provider receives a prior authorization denial due to insufficient information to determine medical necessity, he or she can request reconsideration by submitting a written or faxed request with the requested supportive documentation to Blue Cross of Idaho's Medical Management Department within 60 days of the original authorization denial. Blue Cross of Idaho will issue a reconsideration determination within 14 calendar days of receiving the reconsideration request.

For reconsideration requests for AIM Specialty Health prior authorization denials, please refer to PAP251.

For reconsideration requests for Behavioral Health prior authorization denials, please refer to PAP902.

The following Provider Reconsideration workflow will no longer be in effect after August 31, 2014

Provider reconsideration of prior authorization denials.

Blue Cross of Idaho offers providers two levels of reconsideration review of a denied prior authorization request. Blue Cross of Idaho may offer external review on a prospective review basis. Blue Cross of Idaho does not offer reconsiderations and external review for conditions, services or procedures excluded under the member contract.

Providers must initiate reconsideration requests within 60 days of the original authorization denial letter.

Initial reconsideration - If a provider is dissatisfied with an authorization determination, he or she can request reconsideration by submitting a written or faxed request with additional supportive documentation to Blue Cross of Idaho's Medical Review Department. Blue Cross of Idaho will issue a reconsideration determination within 10 business days of receiving the reconsideration request.  For initial reconsideration requests for AIM Advanced Imaging prior authorization denials, please refer to PAP 251.

Subsequent reconsideration - If a provider is not satisfied with the initial reconsideration determination, the provider may submit a second written or faxed reconsideration request with additional supportive documentation to Blue Cross of Idaho's Medical Review Department. Blue Cross of Idaho will issue a reconsideration determination within 10 business days of receiving the subsequent reconsideration request.

A provider cannot exercise appeal rights on behalf of the member without the member's express written authorization. Our determination of the provider's request for reconsideration does not affect the member's appeal rights under his or her policy.

Retrospective authorizations
Submit retrospective authorization requests along with supportive clinical documentation before, or at the time of, claim submission. We will determine medical necessity based on the information available at the time of claim review. If we deny the claim, the provider may dispute the claim decision with a formal request in writing. Refer to
PAP236 for specific instructions about the Provider Inquiry and Appeal Process.

Advance Beneficiary Notice (ABN)
Contracting providers can collect the entire amount for any services that Blue Cross of Idaho deems “not medically necessary,” only if they attach a “GA” Modifier to the claim indicating that they have an Advanced Beneficiary Notice (ABN) signed by the member stating that the member has agreed to pay for the services even if not medically necessary.

On your remit, charges will show as a contractual adjustment, however, if the member has signed the ABN, you can bill the member for those services. Blue Cross of Idaho considers the ABN and the subsequent bill a matter between the member and the provider.

The ABN should include the following:

  • Member name
  • Member ID number including alpha characters
  • Provider name and address
  • Date of service
  • Procedure codes with descriptions
  • Reason why services may not be covered
  • Estimated charges
  • Statement that the member agrees to make payments to you
  • Date and signature from the member

Refer to PAP248 for an ABN example.

Refer to PAP100 for Medical Management contact numbers.

Refer to PAP279 for Clinical Criteria and instructions on how to obtain a copy of the clinical criteria.


Policy History

Date Action Reason
June 2014 Revised Added Definition of Urgent Care, Added revised provider reconsideration language
October 2013 Revised Added Refernce to PAP279 for Clinical Criteria
August 2012 Revised Removed hysterectomy and lap chole PA forms.
June 2012 Revised Updated online instructions
April 2010 Revised Group disclaimer added, form updated
October 2009 Revised Updated form and formatting
March 2009 Revised Phone number format updated
November 2008 Revised Advanced imaging updated to AIM
May 2008 Revised Updated form

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