to noon, CT on weekends and holidays.įor government programs prior authorization requests handled by eviCore healthcare (eviCore): Phone – Call the AIM Contact Center at 86, Monday through Friday, 6 a.m.Online – The AIM ProviderPortal is available 24x7.By phone – Call the prior authorization number on the member’s ID card.įor commercial prior authorization requests handled by AIM Specialty Health ® (AIM):Ĭommercial non-HMO prior authorization requests can be submitted to AIM in two ways.For instructions, refer to the Availity Authorizations User Guide . Online – Registered Availity users may use Availity’s Authorizations tool (HIPAA-standard 278 transaction).There are two ways to initiate your request. As noted above, when you check eligibility and benefits, in addition to confirming if prior authorization is required, you’ll also be directed to the appropriate vendor, if applicable.įor prior authorization requests handled by BCBSIL: Some requests are handled by BCBSIL others are handled by utilization management vendors. Step 3 – Submit Your Prior Authorization Request Provider name, address and National Provider Identifier (NPI).Date of service, estimated length of stay (if the patient is being admitted).Patient’s medical or behavioral health condition.Step 2 – If prior authorization is required, have the following information ready: Note: Checking eligibility and benefits is key, but we also have other resources to help you prepare. To view requirements summaries and procedure code lists, refer to the Support Materials (Commercial) and Support Materials (Government Programs) pages. In addition to verifying membership/coverage status and other important details, this step returns information on prior authorization requirements and utilization management vendors, if applicable. ![]() Always check eligibility and benefits first, via the Availity ® Essentials or your preferred web vendor, prior to rendering care and services. ![]() Remember, member benefits and review requirements will vary based on service/drug being rendered and individual/group policy elections. Step 1 – Confirm if Prior Authorization is Required In general, there are three steps providers should follow. When and how should prior authorization requests be submitted? For Medicare and Medicaid members, if you don’t get prior authorization for services or drugs on our prior authorization lists, we won’t reimburse you, and you cannot bill our members for those services or drugs.We may conduct a post-service utilization management review, which may include requesting medical records and reviewing claims for consistency with medical policies clinical payment and coding policies and accuracy of payment.The service or drug may not be covered, and the ordering or servicing provider will be responsible.If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists: If the provider or member doesn’t get prior authorization for out-of-network services, the claim may be denied. Note: Most out-of-network services require utilization management review. Information for Blue Cross and Blue Shield of Illinois (BCBSIL) members is found on our member site. Sometimes, a plan may require the member to request prior authorization for services. Usually, the provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. The terms of the member’s plan control the available benefits. A prior authorization is not a guarantee of benefits or payment. Prior authorization is required for some members/services/drugs before services are rendered to confirm medical necessity as defined by the member’s health benefit plan. Our processīased on the clinical information you submit, we conduct a clinical appropriateness review of your requests against clinical guidelines and health plan medical policies, providing you with a central location to obtain authorizations required by your patients’ health plans.Prior authorization (sometimes called preauthorization or pre-certification) is a pre-service utilization management review. And that’s good news for your practice and the patients you serve. ![]() Developed in collaboration with your patients’ health plans, our Radiation Oncology program helps support quality care that is consistent with current medical evidence. Carelon Medical Benefits Management recognizes the key role that radiation oncology practices play in the delivery of care for patients with cancer.
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