BCBS Medicare Prior Authorization

If you have a Medicare plan through Blue Cross Blue Shield (BCBS), it’s important to understand what prior authorization is as it may apply to your unique situation. Here’s everything you need to know about BCBS Medicare prior authorization.

What is Prior Authorization?

Also known as pre-certification or pre-authorization, prior authorization is necessary before some service and drugs are rendered. It verifies medical necessity as defined by your specific health benefit plan. Contrary to popular belief, prior authorization does not guarantee you’ll be approved for a benefit or payment. The terms of your plan will determine this.

There are a number of reasons prior authorization exists. It helps keep insurance costs down and ensures optimal patient safety. Prior authorization can also reduce the risk of duplicate services and improve the effectiveness of treatments.

Does BCBS Require Prior Authorization?

In most cases, the medical provider will need to request prior authorization before they perform a service, if you’re seeing an in-network provider. Your plan may also require that you request prior authorization for services. To determine this, check out the fine print on your plan or visit the Blue Cross Blue Shield website. If there is no prior authorization for out-of-network services, your claim may be denied unless it involves an emergency service.

Once you determine that you need prior authorization, you’ll need the following information on hand:

  • Patient ID, name and date of birth
  • Patient’s medical or behavioral health condition
  • Proposed treatment plan
  • Date of service, estimated length of stay (if the patient is being admitted)
  • Place of treatment
  • Provider name, address and National Provider Identifier (NPI)
  • Diagnosis code(s)
  • Procedure code(s), if applicable

How Long Does It Take for Prior Authorization to Be Approved?

The amount of time it takes for prior authorization to be approved depends on the complexity of your request. You can expect it to take anywhere from a day to a month. If you haven’t heard back after a month, reach out to BCBS for an update.

In the event your prior authorization was denied, you can speak to your doctor about alternative options that are covered by your plan. You may also choose to pay for the procedure or medication out-of-pocket.

What Medical Procedures and Medications Require Prior Authorization?

Only certain medical procedures require prior authorization. Some examples include diagnostic imaging like MRIs, CTs, and PET scans, inpatient hospitalizations services, elective treatments, transplants, skilled nursing visits, home health care services, and infusion therapy. Medical equipment such as chair lifts and wheelchairs may also require prior authorization.

You might also need prior authorization for specific medications. These medications are usually under clinical investigation, cost more than $1,000 per claim, are brand name drugs when A-rated generic equivalents are available, and prescriptions that either exceed the limits of your plan or are processed by out-of-network pharmacies.

Contact MAIR Agency Today

If you’re interested in learning more about prior authorization or would like to find the right health insurance plan for your unique situation, don’t hesitate to contact us today. We’d be happy to answer any questions you may have and guide you through the process.

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