We recently added two lists of procedure codes on our website that require prior authorization. One list of codes will always require prior authorization.
The second list of procedure codes that is subject to BCBSWY medical policies. These procedures may deny for the following reasons if medical policy criteria is not met and an authorization is not on file: no authorization, not medically necessary, experimental/investigational, medical records.
We’re working on developing an easier tool to verify prior authorization requirements, but for now we recommend bookmarking this page and checking it regularly as it will continually be updated.
BCBSWY does allow retro-authorization requests, except for some special circumstances for FEP members.
Medical Records Request
Denial codes shown on your remittance advices may create confusion about when to send in medical records. Please see below for clarification:
- If you see CO252 as the reject code, with the remark N706, it is generally not necessary to submit medical records in response. First, review each line of the remittance advice carefully. There is often one or more lines on the claim that will show what specific information is needed (modifier, post-operational notes, op notes, etc.) Until those specific lines are corrected, all remaining lines will show as “Missing information or documentation”.
- A reject code will generally have a remark code specific to what records are necessary for the claim to process. You may sometimes receive a separate letter requesting medical records. It is important to include a copy of the letter with the medical records so that the claim will process correctly.
We regret that this messaging has often resulted in multiple submissions of medical records and hope this information will help avoid unnecessary processing on your behalf.
BCBSWY Provider Services Reminders
Provider Service Representatives can assist with routine benefits and claims questions. They can also verify receipt of prior authorization requests and status. When calling provider services, you can check the status on up to 5 different policies each time you call.
Hours: Monday – Friday 7:30 a.m. to 5:00 p.m. MT
To comply with HIPAA privacy rules and regulations, Provider Service must verify the identity and authority of each Provider contacting Provider Service. Be prepared to give the following information when calling:
- Caller’s name
- Rendering Provider’s NPI number
- Provider name
- Telephone number
- Patient’s Member ID
- Patient’s name
- Date of service
- Type of service being provided
BCBSWY will be closed on Thursday, November 28 and Friday, November 29 to observe the Thanksgiving holiday.
We hope you enjoy your time with friends and family and have a Happy Thanksgiving. We’re grateful to be able to work with you in your efforts to deliver the highest quality health care to BCBSWY Members.