Prior Authorization Service Request
A Prior Authorization Service Request is the process of notifying BCBSWY of information about a medical service to establish medical appropriateness and necessity of services.
The following information describes the general policies of Blue Cross Blue Shield of Wyoming and is provided for reference only. Pre-admission or prior authorization requests for health care services are NOT A GUARANTEE OF PAYMENT.
How to Determine if Prior Authorization is Required
You can verify coverage or benefits or determine pre-admission or prior authorization request requirements for a Member by going to Availity.com.
Authorization Pre-Check Tool
The Authorization Pre-Check tool allows you to determine if a prior authorization is required for a member upfront. Simply enter the requested information in Availity, and you will get a yes or no answer if an authorization is required.
Keep in mind, this is for BCBSWY members only.
Subject to Medical Policies
BCBSWY recommends authorizing procedure codes associated with BCBSWY medical policies if the medical policy criteria is not met.
CPT codes subject to medical policy may deny for the following reasons if medical policy criteria are not met and an authorization is not on file:
a.) deny for no authorization
b.) deny for not medically necessary
c.) deny experimental/investigational
d.) deny for records
Special Circumstances for Gender Reassignment of Prophylactic Services
Authorization may be required when related to Gender Reassignment or Prophylactic (when the group does not have outright coverage) services.
Benefits will be denied if the patient is not eligible for coverage under the benefit plan on the date services are provided or if services received are not medically appropriate and necessary. Inclusion of a service on this guideline does not guarantee payment.
Visit the Authorization Pre-Check tool at Availity.com.
Complete a Prior Authorization Request
For services which require BCBSWY prior authorization, login to Availity. The Authorization Tool is found under Patient Registration.
You can also complete a Prior Authorization Request Form and submit it as instructed. Medical records will be required with each submission.
Please only mark a prior authorization request as ”URGENT” if failure to receive treatment will result in a life or limb threatening situation. Non-urgent requests marked urgent will delay processing. BCBSWY does not recognize scheduling conflicts as an urgent request.
Processing a Prior Authorization Request
When BCBSWY receives a prior authorization request from a Provider, it will be reviewed by our clinical staff. BCBSWY’s Medical Policies are used in this review. These policies are available online for providers and are searchable by title, CPT code and identification number.
A determination (approved or denied) will be rendered from the information submitted:
- Non-urgent prior authorization requests will be processed within 14 calendar days from date of receipt.
- Urgent* prior authorization requests will be processed within 3 calendar days from date of receipt.
- The Provider, rendering facility and member will be notified in writing of the determination (via U. S. Mail).
- Once a determination has been made a fax response will be immediately sent.
You can use the Availity authorization dashboard to see the status of all authorizations in your organization.
You can also contact BCBSWY Member Services at 800-442-2376 if a determination has not been received within the timeframes shown above.