Section
Provider Prior Authorizations
Policy Date
February 2008
Status / Date
Revised/ February 2024
Provider Type(s)
All Providers
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
Carelon, a specialty benefits management organization, manages Blue Cross of Idaho’s prior authorization requests for advanced imaging, sleep management and musculoskeletal services. We contract with Carelon to manage the use of high-technology outpatient advanced imaging services, clinical appropriateness guidelines for sleep disorder management and musculoskeletal disorders as part of our specialty benefits management program.
Certain Blue Cross of Idaho commercial and all Medicare Advantage members require prior authorization before receiving advanced imaging procedures, sleep management, inpatient or outpatient spinal and orthopedic surgeries.
Prior authorization is not required for groups listed on the Advanced Imaging page on our provider portal. To view the list, log on to our secure provider portal at providers.bcidaho.com, and follow the below steps:
Prior authorization is also not required for enrollees using Blue Cross of Idaho as a secondary insurance.
See PAP100 for Carelon contact information.
MRI/MRA, CT, PET, nuclear cardiology scans, sleep management and spine and orthopedic surgeries (with CPT codes listed on Carelon's prior authorization list) require prior authorization unless the services is part of an acute inpatient or skilled nursing stay, observation care, or occurs during an emergency department visit.
Please note: Spine Surgeries require prior authorization through Carelon beginning November 15, 2018.
OptiNet Registration for Sleep Testing
Registration is required in OptiNet for providers who offer sleep testing and therapy services, including durable medical equipment (DME) suppliers, to Blue Cross of Idaho members. Each servicing location requires a separate registration. Ordering physicians can choose a servicing provider from the on-line directory based on the ability to provide home sleep testing, facility-based sleet testing and DME services.
The registration tool is available through Blue Cross of Idaho's provider portal at providers.bcidaho.com. OptiNet allows you to complete the registration at your convenience. The registration process can be paused and saved as necessary.
Procedure
Submission of Requests for Prior Authorization
For groups participating in Carelon, prior to scheduling an appointment for a non-emergent MRI/MRA, CT, PET, nuclear cardiology, spine surgeries or orthopedic surgeries, the ordering physicians must obtain authorization through Carelon.
Failure to obtain prior authorization will result in a claim denial.
Blue Cross of Idaho providers (ordering and servicing) have up to seven (7) days after the date of service to request a retrospective authorization through Carelon for advanced imaging services, spine and orthopedic surgeries. Although seven (7) days is allowed for a post service review, we strongly encourage participating providers to obtain authorization prior to administering services. Carelon only accepts retro-authorization requests by phone at 866-714-1105.
Carelon will deny authorization requests that are more than seven (7) days past the date of service and will not review them for medical necessity. Blue Cross of Idaho will also deny the resulting claim for lack of authorization. Neither Carelon nor Blue Cross of Idaho will perform medical necessity reviews retrospectively upon provider appeal, unless the provider presents a compelling circumstance explaining the lack of prior authorization. Possible scenarios include:
If you failed to obtain an authorization and provided services more than seven (7) days ago, please refer to PAP263 for a comprehensive list of scenarios which would qualify for a retrospective medical necessity review of services that did not receive prior authorization. Inquiries and appeals in these cases will only be accepted when submitted with evidence of why the prior authorization was not obtained.
Please note:
As a servicing provider, to ensure that you obtain accurate authorization numbers, please consider the following:
Online Authorizations
To submit your online request for prior authorization, log on to our secure provider portal at providers.bcidaho.com.
Prior Authorization by Phone:
Carelon's toll-free number is 866-714-1105, available Monday - Friday, 8 a.m. - 6 p.m. Mountain time. Please have the following information ready when calling the Carelon Utilization Management staff:
If requested by Carelon, please have the following documents ready to fax. Carelon will provide you with the fax number to use:
If a peer-to-peer review is required, the ordering physician or an office staff member can discuss any additional medical information with an Carelon physician reviewer by calling 866-972-9842. Please adhere to the required 24-hour turn-around time and include the clinical information requested by the Carelon physician reviewer.
Specific guidelines about these procedures are available on our secure provider portal at providers.bcidaho.com. To view the guidelines:
Blue Cross of Idaho and Carelon have developed a matrix for providers listing CPT® codes requiring prior authorization through Carelon. The linked matrix contains all the CPT codes Carelon manages on behalf of Blue Cross of Idaho.
Each row represents a family or group of CPT codes, any of which are an authorized CPT code within that group. The matrix does not include codes representing CPT add-on codes, contrast agents, radiopharmaceuticals and supplies. The approval of the primary procedure determines the reimbursement of these associated services.
If the matrix does not list a family or group of CPT codes, an exact match is required between the authorized CPT code and a submitted CPT code on the claim.
The matrix does not include codes submitted by facilities using CMS Outpatient PPS coding (HCPCS codes) or unlisted codes.
Blue Cross of Idaho follows CMS and AMA coding guidelines. Other coding guideline sources are reviewed upon reconsideration only.
Viewing Prior Authorization Letters
Effective early 2024, all Carelon Medical Benefits Management (MBM) provider portal users will be able to view Carelon-generated letters that are attached to an order by using the order search module. Any portal user who has permission to view an order can also see the letters attached to that order. This functionality will be available for all services done by Carelon, including prior authorizations.
Please note that this will replace the previous prior authorization/utilization management mailbox used to find and search for letters.
To view Carelon-generated letters:
If there are no letters attached to an order this message will be displayed: There are currently no letters associated to this order.
Pre-Service Appeals
Blue Cross of Idaho contracting providers have one level of pre-service appeal. For advanced imaging and musculoskeletal services, Carelon conducts this review on our behalf. You can appeal a denied prior authorization request for an advanced imaging study prior to service by contacting Carelon directly at 866-714-1105. Providers may request an appeal within 180 days of receiving a denial letter from Carelon. When Carelon receives an appeal, an appeals coordinator will review the case and facilitate correspondence.
Frequently Asked Questions
A list of frequently asked questions is available on the Advanced Imaging page on our secure provider portal at providers.bcidaho.com. To view the list, follow the below steps:
Date
Action
Reason
February 2024
Revised
Carelon letter updates added
March 2023
Revised
AIM to Carelon
April 2020
Revised
Updated policy from 14 days to 7 days for retro review by AIM
November 2019
Revised
Language clarification
October 2019
Revised
Language clarified for retrospective authorization through AIM
November 2018
Revised
Added language musculoskeletal, spine surgery prior auth requirement
June 2018
Revised
Clarified coding guideline sources
November 2016
Revised
Updated website instructions
September 2016
Revised
Removed echocardiography.
July 2016
Revised
Updated website instructions.
March 2015
Revised
Added language for peer review, revised CPT matrix and clarified one level of pre-service appeal
January 2015
Revised
Added program statement and clarification to review process at AIM and BCI