This will determine if prior authorization will be obtained through us or a dedicated vendor. Step 1: Confirm if prior authorization is required using Availity ® or your preferred vendor. For more information, please refer to your BCBSOK participating provider agreement. Benefits can be verified via the Availity ® Provider Portal or your preferred vendor or by contacting the customer service number listed on the back of the member's ID card.įailure to obtain preauthorization may result in a financial penalty. It is the responsibility of the rendering BCBSOK participating provider to verify eligibility and benefits prior to the date of service. An approved authorization of services by the Prior Authorization process is not a guarantee of benefits. Prior Authorization is a determination of medical necessity for the delivery of services. Should additional days of treatment be deemed necessary, it is the responsibility of the facility, treating physician or ancillary provider to request an extension in accordance with the BCBSOK participating provider agreement. Prior Authorization for an Extension of Approved Days Always check eligibility and benefits first, via the Availity ® Provider Portal or your preferred vendor, prior to rendering care and services.įor additional information, refer the Electronic Provider Access (EPA) FAQs located in the right navigation menu. Other services may also require preauthorization.Inpatient admissions (scheduled and/or nonemergent), certain outpatient services, emergent admissions/obstetric (request authorization within two (2) business days of the admission), requests for extensions and Plan65 Members when their Medicare Part A benefits have been exhausted.Services which may require Prior Authorization
Availity provides administrative services to BCBSTX.The following outlines the process for providers to submit prior authorization requests. Find information about our prior authorization program with AIM at this microsite.ĮviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSTX.ĪIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSTX.Īvaility is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Learn more about utilization management, including prior authorization and post service review, on our website. 1, 2021, follow the instructions in the letter you receive from BCBSTX. The vendor that issued the pre- or post-service adverse determination will process any related peer-to-peer or appeals requests through April 30, 2021. After April 30, 2021, eviCore will redirect any peer-to-peer and appeal requests to BCBSTX. Please note that, for these pre- and post-service adverse determinations, eviCore will continue to process peer-to-peer and appeal requests through April 30, 2021, only. If you submitted a PA (pre-service) request through eviCore and that request was denied or if eviCore conducted a post-service (post-claim) medical necessity review resulting in an adverse determination, your letter will instruct that peer-to-peer discussions and appeals must be requested through eviCore. To assist providers with this transition, in December 2020, a notice appeared on the eviCore website to alert providers of the appeals run-out process, which will continue through April 2021. 1, 2021, AIM Specialty Health ® is the utilization management vendor for Blue Cross and Blue Shield of Texas (BCBSTX) commercial Prior Authorization (PA) requests that were formerly handled by eviCore Healthcare ®. As a reminder, for dates of service on or after Jan.
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