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PAP241 - PRIOR AUTHORIZATION REQUIREMENTS



PROVIDER ADMINISTRATIVE POLICY

Section
General Billing

Policy Date
February 2008

Status / Date
Revised/August 2022

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



Tailored network referral requests - see PAP1005

Medical, behavior health or pharmacy prior authorization requests

Prior Authorization (PA) is the process of determining the medical necessity of
elective procedures, admissions procedures, surgeries services, or medications.

Please note that the treating provider must request PA. However, we will honor
the authorization if all the following conditions are met:

 * The provider is in the same clinic
 * The provider has the same tax ID
 * The provider practices the same specialty
 * The provider has the same contracting status

If the service performed is being billed by a facility, the authorization should
be requested using the facility number.

The terms of the member specific benefit plan document may be different than the
standard benefit plan. If there is a conflict between a member specific benefit
plan and the Blue Cross of Idaho’s standard benefit plan, the member specific
benefit plan supersedes. The process involves working with providers to obtain
the necessary medical records and treatment plan to determine the medical
necessity for the planned services.

Use the Prior Authorization Procedure Code Lookup tool to determine whether a
service or procedure requires prior authorization approval. A service that does
not require PA is not a guarantee the service or procedure is a covered benefit
on your patient’s policy. Services that are considered investigational or
experimental per medical policy 9.01.502 will indicate no authorization is
required on the Prior Authorization Lookup tool. PA approval is a determination
of medical necessity only and not a guarantee of reimbursement.

Medical/Behavioral Health Requests:

Elective PA requests must be submitted at least 14 days prior to the scheduled
date of service. For contracting providers the requesting/treating provider
should submit the PA request by logging on to our secure provider portal at
providers.bcidaho.com.

 * Hover over Authorizations/Notifications
 * Select Medical/Behavioral
 * Select LAUNCH
 * Select  New Request

If you need training or assistance with the provider portal for submission of
online authorizations, please contact Provider Relations at
PRexternalreps@bcidaho.com. 

Non contracting providers submit PAs by fax or mail:

Fax: 

Please print and fill out the appropriate form and fax to number listed on the
form.

Mail: Blue Cross of Idaho
Attn: Healthcare Operations, Clinical Review
Department
PO Box 7408
Boise, ID 83707
Confidential Prior Authorization Request

For all PAs, please include the following information:

 * All medical records documenting the clinical indications and/or medical
   necessity
 * Contact information for requesting and treating providers and facilities with
   phone and fax numbers

Expedited Request:

Expedited request is any request for medical care or treatment which the time
periods for making non-urgent request determinations could result in the
following circumstances and must be attested to by the ordering provider:

 * Could seriously jeopardize the life or health of the member, or the 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.

Please note:

 * A new request for a service previously denied as not medically necessary, may
   be submitted as a new prior authorization request only after 90 days has
   passed after the initial submission.
 * Blue Cross of Idaho sends notification of denials only.

You can view the status and determination of the requested prior authorization
by logging on to our secure provider portal at providers.bcidaho.com.

 * Hover over Authorizations/Notifications
 * Select Medical/Behavioral
 * Select LAUNCH

Drug Replacement Policy

If you have patients enrolled in a drug replacement program that furnishes or
replaces the medication free of charge, but you need to submit a claim for the
administration costs, please follow the instructions listed below:

When completing the prior authorization form for the medication, place a note on
the prior authorization request indicating that the drug company will replace
the medication to you at no cost. Blue Cross of Idaho's Healthcare Operations
department will append a note to the prior authorization in our system to
instruct the claims examiner to zero-price the medication when processing the
claims. This will allow consideration of the administration charges for covered
medications but will not reimburse the medication.

If the medication requires prior authorization and none was obtained, any
associated charges for that medication such as administrations charges will deny
for no prior authorization.

If the medication does not require prior authorization and you want the
administration cost considered for payment, bill the medication with charges of
less than $1.00 along with the administration fee. Claim will be considered for
payment. If you submit a claim with charges for the medication and they are
paid, a request will need to be submitted through our secure provider portal to
request recoupment of the medication payment. Contact provider relations  at
866-283-5723 option 4 if you need assistance in how to submit this request.

Retrospective Authorization

Blue Cross of Idaho does not accept requests for retrospective authorizations.
If a provider does not obtain prior authorization before rendering services, the
provider should submit a claim for processing. If denied, the provider may
dispute the claim decision by formally requesting a provider appeal. A provider
appeal request must include supporting documentation. Blue Cross of Idaho will
not perform medical necessity reviews retrospectively upon provider inquiry or
appeal, unless the provider presents a compelling circumstance explaining the
lack of PA as noted in PAP263, Medical Necessity Reviews for Non Authorized
Services.

Pre-Service Provider Appeals

Blue Cross of Idaho does not offer providers any appeal options for services,
therapeutics or procedures excluded under the member contract.

Providers may submit one (1) pre-service provider appeal to review a denial of a
request for prior authorization, out-of-network services, admission to a
hospital or a decision made by Blue Cross of Idaho during its concurrent review.
We reserve the expedited appeal process for urgent care situations, when a delay
in medical care or treatment:

 * 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 judgement,
   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 immediate care or treatment

If we approve the pre-service provider appeal, we notify the provider in writing
that we authorize the service(s).

If we deny a pre-service provider appeal, and the provider chooses to render the
services anyway, we will deny the subsequent claim as not medically necessary.
We will also hold the provider financially liable in the form of a contractual
obligation on the remittance advice.

We handle all pre-service provider appeals as follows:

Standard - Must be submitted within 14 days of the original authorization
denial. Blue Cross of Idaho will respond within 15 days of receiving the
request.

Expedited - Must be submitted within three (3) days of the original
authorization denial. Blue Cross of Idaho will respond within three (3) days of
receiving the request.

Please submit all pre-service provider appeals with supporting clinical
information by fax:

Behavioral Health: 208-387-6840 Commercial and FEP: 208-331-7344 Inpatient:
208-331-7326 Pharmacy: 208-387-6969 QHP: 208-286-3583

Peer-to-Peer Reviews

Peer-to-peer discussions with a Blue Cross of Idaho physician or other
appropriate reviewer for adverse PA determinations can be submitted to
Healthcare Operations at Peer2PeerRequests@bcidaho.com within five (5) business
days of the denial to ensure current treatment needs are reviewed.

For same day peer-to-peer reviews, call 888-970-0661. Peer-to-peers are not
available for adverse determinations related to contract or benefit exclusions.

Prior Authorizations When Blue Cross of Idaho is Secondary

PA 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 may
require a post-service review if there is no authorization on file. All
services, whether primary or secondary, may be subject to medical necessity
review.

AIM Specialty Health (AIM)

For services authorized through AIM, please refer to the following PAPs:

 * PAP219 - AIM Specialty Health Prior Authorization
 * PAP285 - AIM Specialty Health Sleep Testing and Therapy

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

Once submitted, 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

Pharmacy Requests:

A list of medications requiring PA is available by logging on to our secure
provider portal at providers.bcidaho.com.

 * Select Forms & Resources
 * Select Pharmacy
 * Select Prior authorizations & Step therapy

Elective PA requests must be submitted at least 10 days prior to the scheduled
date of service. The ordering physician should submit the PA request by logging
on to our secure provider portal at providers.bcidaho.com.

 * Hover over Authorizations/Notifications
 * Select Medical/Behavioral
 * Select LAUNCH
 * Select New Request

If you need training or assistance with the provider portal for submission of
online authorizations, please contact Provider Relations at
PRexternalreps@bcidaho.com.

PAs may also be submitted by fax or mail:

FAX: Please print and fill out the appropriate form and fax to the number on the
form. Mail:                                                                     
                                                  

Blue Cross of Idaho
Attn: Healthcare Operations, Clinical Review Department
PO Box 7408
Boise, ID 83707
Confidential Prior Authorization Request

 







 

NOTE: For all PAs, please include the following information:

 * All medical records documenting the clinical indications and/or medical
   necessity
 * Mark Expedited Request if the determination is needed immediately include the
   reason for the request. We will honor urgent requests if the documentation
   supports the definition of urgent care as attested to by the ordering
   provider.

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.

Blue Cross of Idaho follows Centers for Medicare and Medicaid Services (CMS) and
American Medical Association (AMA) coding guidelines. Other coding guideline
sources are reviewed upon reconsideration only.



POLICY HISTORY

Date

Action

Reason

August 2022

Revised

Added clarification about E & I

August 2021

Revised

Added verbiage from PAP 268 regarding drug replacement policy

November 2020

Revised

Updated process and verbiage

November 2019

Revised

Updated phone number for Pharmacy

August 2019

Revised

Added pre-service provider appeal language from PAP 236 and modified PAP for
clarity of processes

June 2018

Revised

Clarified coding guideline sources

April 2018

Revised

Added language regarding authorization notifications previously communicated in
11/30/15 alert.

November 2017

Revised

Added link to the Prior Authorization Lookup tool

October 2017

Revised

Clarified retrospective referral language

October 2016

Revised

Removed ConnectedCare language. Updated website instructions.

March 2016

Revised

Updated retrospective referral information.

February 2016

Revised

Updated information on how to view status of an authorization and path to access
provider portal

May 2015

Revised

Added information regarding retrospective authorizations effective May 1, 2015.

March 2015

Revised

Added links to AIM PAPs and attestation for urgent requests

January 2015

Revised

Removed all reference to a 'reconsideration' process and pointed all providers
to PAP236

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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