You will soon be able to submit prior authorizations through Availity again. This will be the best and most efficient way to submit a prior authorization.
Continue reading “Availity: Prior Authorizations Go Live Next Monday”
Submitting a prior authorization through Availity is the best way to determine prior authorization requirements for a participant.
Additionally, understanding the proper Service Type makes a difference in how the prior authorizations get routed and the associated approval time.
Please view the short videos below to understand these workflows better.
Follow this video to understand the basics of submitting a prior authorization.
When submitting an authorization, you will need to select a Service Type. This routes your case to BCBSWY subject matter experts who will review and render a determination. Therefore, selecting the correct service type is key to receiving the most effective and efficient service from our authorizations team.
The videos below have additional information to help you better understand the prior authorization workflows. Choose the service type that aligns with your facility.
Explore our comprehensive video library, a valuable resource providing in-depth training on various Prior Authorization topics. Access expert insights and educational content to enhance your understanding and skills in this crucial field.
If you have any questions regarding prior authorizations, call +1-800-442-2376.
Online Prior Authorizations Submissions are unavailable until 9/18.
Soon you can experience: More real-time information; Reduced wait times; Auto-approval of some authorizations.
We appreciate your patience.
Continue reading “Workflow and Updated Prior Authorization Guide Available”
Online Prior Authorizations Submissions will be unavailable between 9/1 – 9/18. Continue reading “Prior Authorization Update Soon”
Our new Prior Authorization tool, Predictal, will launch September 5th. We
look forward to the convenience it will offer you. We will provide you with
additional training resources very soon. For now, we would like you to
please note the important following details:
We will share additional information very soon. Please reach out if you
have any questions.
As we enter our busy season, we want to remind providers that if you
receive a claim that is denied for “no authorization,” the quickest route of
reprocessing a claim for payment is to submit the missing authorization
through the standard authorization process. Please note that you are
submitting based on a denied claim on your cover page of documentation
or on your fax. Include the claim number.
Our clinical team will process the authorization and reprocess your claim
based on the review outcome. This will either allow your claim to be
processed for payment or provide you the appropriate appeal rights based
on the denial reason.
We recommend this method instead of submitting an appeal due to the
turnaround times. We would expect that your claim will receive an
authorization determination and claims reprocessing within 30 days. Note:
If submitting an appeal, the expected timelines could extend significantly
past 30 days.
BCBSWY is not accepting billing of consolidation codes for mental health
and substance abuse such as G2087 and G2088. To receive
reimbursement for the different services listed under these codes, submit
the individual codes for the services rendered to the member.
These will be reviewed per the members benefit plan and reimbursed in
accordance with the BCBSWY fee schedule.
BCBSWY is seeing an uptick in billing of implantable infusion pumps (HCPCS Code E0782) billed without a required modifier for pricing. For claims to be reimbursed, providers must submit this code with one of the following modifiers:
When submitting a HCFA-1500 with an unclassified drug HCPCS code, such as J3490 or J3590, the units billed with the code will specify the units for which you are seeking reimbursement.
For example, Xylocatine-MPF 1% Solution is provided in a package size of 2.0 ML. On a claim form 1 unit would indicate usage of 2.0 ML, 2 units would indicate usage of 4.0 ML. The units billed in loop 2410 within an 837p file is not referenced for pricing and will not cause a multiplication of the per unit price.
Beyfortus (nirsevimab-alip) received an FDA approval for the prevention of RSV in neonates and infants born during or entering their first RSV season and in children up to 24 months of age who remain vulnerable to severe RSV Disease through their second RSV season.
BCBSWY will NOT require authorization on Beyfortus.
Please bill using the following codes for Beyfortus:
Authorization is still required for Synagis for treatment of RSV. For authorizations, you should expect up to 14 days for processing. We encourage you to review our RSV medical policy found at BCBSWY.com/providers to help you understand what our clinician are reviewing for and where you may need to provide additional documentation if your patient does not meet the criteria outlined. The medical policy number for reference is 05.01.10.
Starting in July of 2023, we will no longer accept faxes from Providers. Please use the Availity attachments tool to upload all documents, such as medical records, appeals, adjustments, invoices and general medical documentation. For more information on the Availity attachment tool, please click the button below.
How to Use the Availity Tool Guide Here
As of July 14, BCBSWY now accepts electronically corrected claims. Please use the appropriate frequency code or type of bill to correct your electronic claim. For more information, please download the instructions below.
View Electronic Claims Adjustment Instructions Here
BCBSWY would like to welcome the North Platte Valley Medical Center to Saratoga where they began seeing patients as of May 30, 2023. We wish you success in your community!
Reminder: You can now find the guide under the Provider Resources section on the right rail of the website.
Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.
The No Surprises Act (NSA) requires you confirm this information with us every 90 days.
Holiday Closures
BCBSWY is updating its DME reimbursement rates. Effective August 1, 2023, our DME reimbursement will be based on Medicare’s DMEPOS 2023 non-rural schedule.
In observance of Memorial Day, our offices will be closed Monday, May 29, 2023.
BCBSWY reviews claims for Excludes 1 Note instructions per the ICD -10- CM Official Guidelines for Coding and Reporting.
An Excludes 1 Note indicates that two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Billed services with one or more diagnosis code pairs that are subject to an Excludes 1 Note will be denied.
Please join BCBSWY for a webinar with Itiliti and ACAP on June 1, 2023 at noon. You do not need to be an ACAP member to register. All BCBSWY providers are encouraged to attend.
BCBSWY and ACAP will discuss how BCBSWY has reduced the burden of prior authorizations within the company and for providers. Please register using the button below.
Reminder: You can now find the Availity Directory Validation Training guide under the Provider Resources section on the right rail of the website.
Providers can use the Directory Validation tool on the Availity Portal to find NPI and tax ID combinations.
The No Surprises Act (NSA) requires you confirm this information with us every 90 days.
Effective Jan. 1, 2023, BCBSWY has updated our telemedicine guidance. BCBSWY will permit telephonic and telemedicine visits to occur at the patient’s home. Inpatient telemedicine encounters are permitted within the same facility. The below guidance is intended to assist professional providers understand the types of services permitted during this time. Other benefit and cost share rules will continue to apply. It is important to note that only services that can be rendered through telemedicine should occur. Services that cannot be safely or adequately provided through telemedicine should be avoided. These guidelines apply only to BCBSWY members. Providers should seek guidance from other Blues plans for potential changes to their policies.
Please refer to the Provider Manual for more detailed guidance here.
| Type of Service | What is the Service | HCPCS/CPT Codes | Place of Service/Modifiers | Coverage |
|---|---|---|---|---|
| Inpatient (Professional Services) Telehealth/Telemedicine Visits | A service that can safely and appropriately be rendered at a distance. Services provided should be within the provider’s scope of license and meet the standard of care. | HCPCS or CPT code(s) that can safely and appropriately be rendered at a distance as determined by BCBSWY. | Append a GT or 95 modifier as applicable with correct coding. Bill with the place of service of inpatient hospital. | BCBSWY covers telemedicine services subject to member’s benefits. |
| Outpatient (Professional Services) Telehealth/Telemedicine Visits | A service that can safely and appropriately be rendered at a distance. Services provided should be within the provider’s scope of license and meet the standard of care. Services can be rendered to the patient’s home. | HCPCS or CPT code(s) that can safely and appropriately be rendered at a distance as determined by BCBSWY. | Append a GT or 95 modifier as applicable with correct coding. | BCBSWY covers telemedicine services subject to member’s benefits. |
| Telephone Services | Telephone evaluation and management service by a physician or other qualified health professional for an established patient. | 99441 99442 99443 | Use standard place of service codes. The GT or 95 modifier is not required. | BCBSWY will benefit these services. |
| e-Visits | Online digital services for an established patient, through an online patient portal. | 99421 G2061 99422 G2062 99423 G2063 | Not applicable. | Not a benefit. These codes are not reimbursed by BCBSWY at this time. |
| Virtual Check-Ins | Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient. | G2010 G2012 | Not applicable. | Not a benefit. These codes are not reimbursed by BCBSWY at this time. |
| Hospital Staff Mental Health and Substance Use Treatment | Diagnosis, evaluation, or treatment of a mental health or substance use disorder provided remotely by hospital staff who are licensed when the patient is in the home place of service. | C7900 C7901 C7902 | Not applicable. | BCBSWY will deny these codes as included in. Provider should bill the specific service rendered on a professional claim (HCFA-1500, 837P) with a GT or 95 modifier. You must bill with the national place of service 10 (Telehealth Provided in Patient Home). |
| Home Health Telemedicine | Home health services rendered using audio and/or video telecommunications including remote monitoring. | G0320 G0321 G0322 | Not applicable. | BCBSWY will deny these codes as included in. Provider should bill the specific service rendered on a professional claim (HCFA-1500, 837P) with a GT or 95 modifier. You must bill with the national place of service 10 (Telehealth Provided in Patient Home). |
Provider Training Guides
View our Online Medical Document Attachment Training Guide.
View our Prior Authorization Online Training Guide.
Learn how to submit EFT requests through the Availity portal.