BCBS Prior Authorization

purpose to submit and document a bcbs prior authorization (pa) request for rehabilitation services through the health management portal, and to confirm whether the patient’s policy requires authorization when use this process when a patient has bcbs insurance and the office needs to verify or obtain prior authorization for rehabilitation/physical therapy services who this process should be completed by the insurance verification / prior authorization coordinator, ca, or designated front office team member responsible for authorizations procedure 1\ log into the bcbs website log into the bcbs provider portal using the office credentials purpose to access the patient’s benefit and authorization tools 2\ open health management from the main portal, click health management purpose this section contains the authorization and specialty care request options 3\ enter the member id prefix in the member id prefix field, enter the first 3 characters of the patient’s insurance policy number examples yps y2u purpose this directs you to the correct bcbs plan and authorization pathway 4\ open diagnostic and specialty care click the diagnostic and specialty care link this will open in a new window purpose this is where rehabilitation requests are started 5\ select rehabilitation and start order request once the patient information is loaded, select rehabilitation and then click start order request if rehabilitation cannot be selected this means the patient’s policy does not require prior authorization for rehab in that case select print preview save the preview for documentation make an alert in the patient chart stating that no pa is required for rehab per bcbs portal purpose to confirm whether authorization is required before moving forward 6\ confirm patient information review the patient’s information for accuracy, then click continue purpose to ensure the request is attached to the correct patient condition & services section 7\ enter diagnosis and service code enter the patient’s chief diagnosis code if unsure, ask dr mays for back pain, enter m99 03 service/cpt code 97140 purpose to identify the condition being treated and the service being requested 8\ select therapy type for therapy type , select physical therapy , then save purpose to classify the request correctly clinical questions 9\ autism services question question is this a request to provide autism services for a confirmed diagnosis of autism spectrum disorder or pervasive developmental disorder ? select no purpose this question does not apply to standard chiropractic rehab requests 10\ initial evaluation performed question was an initial evaluation performed by a therapist or a licensed qualified provider of therapy services? select yes purpose confirms that the patient has already been evaluated 11\ enter initial evaluation date enter the patient’s initial evaluation date refer to date of onset , or soap note purpose this supports medical necessity and treatment timing 12\ functional tool for functional tool , select odi – oswestry low back pain disability questionnaire (0–50 points) then click add tool enter the patient’s score purpose this provides measurable functional limitation data required to continue provider information 13\ ordering provider search search for clifton mays city high point purpose to assign the request to the correct provider 14\ select provider under provider results , choose the first option then check the box ordering provider is also the treating therapist purpose to correctly link the rendering and ordering provider 15\ servicing facility billing question question will the servicing facility be billing for the request? select yes purpose confirms the treating office is the billing location 16\ confirm facility the office should populate automatically select it and confirm it is listed as an office , then continue purpose ensures the request is tied to the correct facility start clinical 17\ primary purpose of therapy question which of the following best describes the primary purpose of therapy? select rehabilitation purpose identifies the overall treatment goal 18\ primary treatment method question will any of the following be used as a primary treatment? select none of these apply purpose confirms that no special treatment category applies 19\ complexity level question what is the complexity level of the evaluation or e\&m equivalent that was completed for this request? confirm this option with dr mays , then select moderate complexity (cpt 97162 or e\&m 99203, 99204) purpose ensures the clinical level selected matches the provider’s evaluation 20\ recent surgery question question did the patient have a surgical procedure in the last three (3) months related to the conditions for which services are being requested? select no purpose determines whether post surgical criteria apply 21\ onset timing question question did the onset of the injury or condition occur within the last six (6) months? select yes purpose supports the rehabilitation timeline and medical necessity 22\ complex condition question question is the requested treatment for a complex neurological, medical, or multi trauma condition? select no purpose confirms this is a standard rehab request 23\ conditions impacting treatment question select all conditions expected to impact treatment select none of these apply purpose indicates there are no additional complicating factors affecting care 24\ attestations complete all required attestations and click save purpose finalizes the clinical details required for submission 25\ contact information prompt if prompted for both the patient’s phone number and email, select unable to provide both in order to continue purpose allows the request to move forward if complete contact details are not available final review and submission 26\ review print preview select preview and carefully verify that all information is correct check patient information diagnosis code cpt code evaluation date odi score provider and facility details purpose prevents errors before submission 27\ submit order submit the order purpose sends the pa request for review 28\ accept and update order in most cases, you should receive immediate results when prompted select yes to accept update the order as required purpose completes the authorization process and records the result documentation after completion, document the outcome in the patient chart include whether pa was approved, not required, or pending authorization/order number if applicable date completed any saved print preview or confirmation purpose maintains accurate records for billing and follow up quick notes if rehabilitation is not selectable, the policy does not require pa for rehab save the print preview add a chart alert if diagnosis or complexity level is unclear, confirm with dr mays