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VISUAL UPDATE TO MEMBER ID CARDS: SUITCASE SYMBOL BEING PHASED OUT We want to make you aware of a recent change to the design of member ID cards that may impact your front-office staff and billing teams. What’s Changing? The familiar ‘suitcase’ symbol used to indicate BlueCard program participation…
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BCBSWY Newsroom
- BCBSWY News, BCBSWY Press Releases
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Blue Cross Blue Shield of Wyoming Announces New Board Member
- BCBSWY News, BCBSWY Press Releases
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Annual Medicare Advantage Plan Enrollment Period begins Oct. 15
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 or if the member has severe pain that cannot be adequately managed without the care or treatment being requested*. 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 5 calendar days from date of receipt.
- Urgent* prior authorization requests will be processed within 72 hours 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.
Checking Status
You can use the Availity authorization dashboard to see the status of all authorizations in your organization.
Contact Us
You can also contact BCBSWY Provider Support at 888-359-6592 if a determination has not been received within the timeframes shown above.
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Prior Authorization Admission Request
A Prior Authorization Admission request is the process of notifying Blue Cross Blue Shield of Wyoming (BCBSWY) of an inpatient stay. The participating Provider or Member must notify BCBSWY of ALL inpatient stays including emergency admissions. When a patient is transferred from one facility to another, the Provider of the receiving facility should notify BCBSWY.
Our policies begin with the following prefixes:
- QWY
- YWY
- ZRW
- ZSD
- ZSF
- ZSH
- ZSK
- ZSM
- ZSP
- ZYW
- R (FEP)
For all other prefixes, please call 1-800-676-2583 to find the Blue Cross Blue Shield Plan you will need to contact for Prior Authorization Admission requests.
Complete a Prior Authorization Admission Request:
A provider should submit an admission request to BCBSWY when:
- A patient is being scheduled for an inpatient stay
- A patient is being admitted for an inpatient stay
- A patient is a FEP member and is in an observation status greater than 48 hours
A provider does not need to submit a request to BCBSWY when:
- A patient is a FEP member and is in an observation status less than 48 hours
- A patient is on Medicare and has a contract number beginning with ZSM
To Get Started
- Log in to Availity. The Authorization Tool is found under Patient Registration. Complete the prior authorization service request (if required) AND admission request.
- You should only call 307-829-3081 to request the following admissions: Skilled Nursing Facilities, In-Patient Hospice Care, Acute Rehabilitation Facilities, Transitional Care Units, Swing bed admissions, Residential Treatment Facilities. Be prepared to include the following information:
- Name of caller, caller’s facility, and caller’s phone number
- Name of patient, patient’s date of birth, patient’s policy number
- Date of admission
- Admitting diagnosis including diagnosis codes
- Admitting procedure including CPT codes
- Physician’s name including spelling, physician’s address and fax number
- Facility name, facility address and fax number
- Type of stay – Outpatient, Observation, or Inpatient
Concurrent Review
Once a patient has exhausted their initial authorized length of stay, you can request an extension through the Availity portal, if the request was initiated using Availity. BCBSWY requires notification of discharge date.
First, go to Authorization Dashboard and find the Inpatient authorization that requires an extension. Then, select Update. Follow the prompts to complete the request. See this step by step guide to see how to request additional inpatient days through Availity.
Providers can also call 800-251-1814 or fax a request to the Concurrent review fax number at (307) 432-2756 requesting an extension.
BCBSWY requires notification of discharge date and you can fax this to the concurrent review fax number, (307) 432-2756, or call 800-251-1814.
Special Circumstances
Transplants
For questions about transplants or authorizations call our transplant coordinator 307-829-3081.
Residential Treatment Facility
For questions about residential treatment facility (RTF) authorizations call
844-946-6319.
Newborn Admission Request
Admission requests are not required per the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) unless the newborn is admitted for more than 48 hours or 96 hours in the case of cesarean delivery.
FEP Prior Authorization
For authorizations of the following services, please contact FEP case management at 1- 800-210-7257.
- Applied Behavioral Analysis
- Gender Reassignment
- Residential Treatment Facility*
- Skilled Nursing Facility/Center*
* FEP does not permit retroactive authorizations.
Checking Status
You can use the Availity authorization dashboard to see the status of all authorizations in your organization.
Contact Us
Providers
Call Utilization Review staff at 800-251-1814 with questions, concerns, or to complete an update.Members
Call Member Services at 800-442-2376| Document Destination | Fax Number | What should be sent here? |
| Authorizations | 307-432-2917 |
|
| Concurrent Review | 307-432-2756 | Updates and records for current inpatient hospital stay |
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Medical Policy Information
The medical policies are developed under guidance of the Internal Medical Policy Committee. The Committee is composed of Blue Cross Blue Shield of Wyoming clinical and coding staff with medical policy accountability. This Committee provides a formal internal review for consensus, awareness and implementation throughout the company.
How Is Medical Policy Evaluated?
The Internal Medical Policy Committee reviews “investigational” medical technologies according to the following technology assessment criteria which have been established by the national Blue Cross Blue Shield Association (BCBSA) and endorsed by BCBSWY:
- The technology must have final approval from the appropriate government regulatory bodies.
- The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
- The technology must improve the net health outcome.
- The technology must be as beneficial as any established alternatives.
- The improvement must be attainable outside the investigational settings.
“Medical necessity” means a medical service, procedure or supply provided for the purpose of preventing, diagnosing or treating an illness, injury, disease or symptom and is a service, procedure or supply that:
- Is medically appropriate for the symptoms, diagnosis or treatment of the condition, illness, disease or injury;
- Provides for the diagnosis, direct care and treatment of the patient’s condition, illness, disease or injury;
- Is in accordance with professional, evidence based medicine and recognized standards of good medical practice and care; and
- Is not primarily for the convenience of the patient, physician or other health care provider.
Sources for Policy Development
Blue Cross Blue Shield Association
- The Office of Clinical Affairs serves as a technical resource on medical policy issues to Plans.
- The Association’s Technology Evaluation Center (TEC) provides scientific analysis and opinions of complex medical technology issues. This information allows Plan medical personnel to make decisions about which treatments best improve a patient’s health outcomes, resulting in efficient use of health care resources
- TEC is guided by the Association’s Medical Advisory Panel (MAP), a panel comprised of nationally recognized experts in technology assessment, clinical research methodology and implementation, and clinical practice.
Specialty Input
- External Review Organization reviews appeals
Centers for Medicare & Medicaid Services
Member Services/Provider Services
Inquiries about our medical policies can be made to BCBSWY Member Services. Members may also wish to discuss their questions and individual medical situations with their physician. Physicians may want to share documentation with BCBSWY about recent medical advances and guidelines that could enhance our medical policies by contacting BCBSWY Provider Relations.
BCBSWY Member Services
PO Box 2266
Cheyenne, WY 82003
800.442.2376
BCBSWY Provider Relations
PO Box 2266
Cheyenne, WY 82003
888.666.5188
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Medical Policy
Guidelines for Coverage Decisions
BCBSWY has developed medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some BCBSWY plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, in effect at the time services are rendered and also subject to applicable state and/or federal laws. Medical policy does not constitute plan authorization, certify coverage availability, or constitute a contract. Medical policies are not an explanation of benefits. These medical policies generally apply to all BCBSWY fully insured benefit plans, although some variations may exist. Additionally, some benefit plans administered by BCBSWY, such as some self-funded employer plans, may not utilize BCBSWY medical policy. Members should contact a BCBSWY Member Services representative for specific coverage information.
Medical policies can be highly technical and complex and are provided here for informational purposes. These medical policies do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. BCBSWY members should discuss the information in the medical policies with their treating health care providers. Medical policies detail when certain medical services are medically necessary, and whether or not they are investigational. These policies are written to cover a given condition applicable to a majority of people without taking into consideration each individual’s unique, clinical circumstances. Medical policies are medical determinations about a particular technology, service or drug that, while such technology, service or drug may be medically necessary, it is excluded under the terms of a member’s benefit plan. Medical policy is NOT intended to replace independent medical judgment for treatment of individuals.
Medical technology is constantly evolving and these medical policies are subject to change without notice. Additional medical policies may be developed from time to time and some may be withdrawn from use. BCBSWY reserves the right to review and update its medical policies periodically, without notice, and changes may not appear on this web site. BCBSWY makes all coverage determinations based on current medical policy or policies in effect at the time.
Medical Policy Updates
Review medical policy and medical necessity changes to be implemented in the next 60 days or more.
Provider Resources
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Credentialing Guidelines
Welcome to Blue Cross Blue Shield of Wyoming (BCBSWY)! We are pleased that you are considering becoming one of our participating providers. The following pages contain some basic guidelines about our credentialing process.
What is credentialing?
The credentialing process allows us to review, evaluate and approve (or disapprove) a provider to participate in our network(s). This ensures that each network provider is qualified by education, training, licensure and experience to deliver quality health care services to our members.
Who needs to be credentialed?
The credentialing process needs to be completed by all providers who wish to provide covered health care services to our members and are requesting network participation with BCBSWY. This includes:
Institutions: including Hospitals, Hospice and Skilled nursing
Facilities: Labs, DME, ASCs, Home Health
Licensed and independent practitioners
Types of individual providers that are required to be credentialed include, but are not limited to:
- MD/DO/DPM
- Advanced Practice Registered Nurse (CNM, CNP, CRNA, CNS)
- Audiologist
- Certified Diabetic Educator
- Chiropractor
- Dentist
- Licensed Addiction Counselor
- Licensed Independent Certified Social Worker
- Licensed Professional Clinical Counselor
- Licensed Registered Dietitian
- Occupational Therapist
- Optometrist
- Physical Therapist
- Physician Assistant
- Psychologist
- Speech/Language Therapist
What are our credentialing criteria?
To qualify for network participation, applicants are required to meet the following criteria, as applicable:
Applicant Criteria
Required Application Information
Applicant Criteria
- For participating Providers, login to CAQH.org to complete the application process and grant BCBSWY access.
- For Institutions/Facilities submit a fully completed, signed application to BCBSWY through DocuSign. Request an application.
- Maintain staff appointment in a network hospital or facility, as applicable.
- Possess required education from an appropriately accredited school.
- Successful completion of post graduate residency training or specialty board certification, as applicable.
- Possess a valid, active license, DEA and controlled substance registration in the State of Wyoming, as applicable.
- Have the required levels of individual professional liability coverage. Recommended levels of coverage are $1 million per incident and $3 million aggregate.
- Be free of conviction for any criminal offense punishable as a felony, or engagement in any improper act related to the qualifications, functions or duties of a Provider.
- Maintain absence of Medicare/Medicaid sanctions, fines, fraud or suspensions from either program.
Required Application Information
All providers who apply for participation in a BCBSWY network(s) are required to complete an application.
This grid outlines the required information for all applicants:
| Institution | Facility | Practitioner | |
| Updated 5/2024 | |||
| Practitioner’s education and professional training history (including Board certification status if applicable) | Checked | ||
| An up-to-date history of all licensure | Checked | ||
| Documentation of current controlled dangerous substance certificates, federal (DEA) and state (if applicable) | Checked | ||
| Facility License | Checked | Checked | |
| NPI Number | Checked | Checked | Checked |
| Proof of Liability Insurance | Checked | Checked | Checked |
| Liability Claims History | Checked | Checked | |
| History of Loss of License and felony conviction | Checked | Checked | |
| History of loss of privileges, sanctions, and disciplinary action | Checked | Checked | |
| Disclosure of listing on the List of Excluded Individuals/ Entities (LEIE) | Checked | Checked | |
| Disclosure of any issues that could impede the practitioner’s ability to provide quality health care services | Checked | ||
| An attestation that the application is complete and accurate | Checked | Checked | Checked |
| A statement authorizing BCBSWY to collect verifying information (signed and dated by applicant) | Checked | Checked | Checked |
| On-site visit as requested by the CRC | Checked | Checked | Checked |
When is credentialing performed?
Completion of the credentialing process is required prior to a provider participating in our network(s). Participation with BCBSWY cannot be dated prior to approval of the credentialing application.
What is re-credentialing?
At minimum, BCBSWY conducts re-credentialing of each participating provider at least every three (3) years. In the third year of the credentialing cycle, BCBSWY requests providers complete a re-credentialing application that requires providers to update information and elements that are subject to change and need to be re-verified.
BCBSWY uses CAQH to streamline the credentialing process. When it’s time to be re-credentialed, BCBSWY will send you an email with your CAQH Proview Provider Number. Once you have received your ID Number, login to CAQH ProView and follow the prompts to get started.
Already Registered with CAQH ProView?
If you have already created your CAQH ProView account, please follow these tips to help ensure that your current information is accurate:
- Login to CAQH ProView to update and re-attest to your CAQH profile every 120 days.
- Replace expired documents with new ones.
- Leave no gaps in your work history for the most recent five years, or list the reasons for any gaps as appropriate; e.g., leaves of absence, maternity leaves, illness, etc.
- Ensure that a current copy of your liability insurance is attached to your CAQH profile.
- If you only authorize specific organizations access to your profile, please add Blue Cross Blue Shield of Wyoming.
How do I start the credentialing process?
In order to begin the credentialing process please:
- For Institutions/Facilities contact BCBSWY to request an application, signed application to BCBSWY through DocuSign. Request an application.
- Review the credentialing criteria in this document.
- Register or login to CAQH, complete your profile, and grant BCBSWY access
- Complete the credentialing application and attach all required materials.
- Return the application to BCBSWY as instructed.
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What happens next?
- When your credentialing application is received by BCBSWY, our credentialing staff will review it for accuracy and completeness.
- Our credentialing staff will then conduct a Primary Source Verification (PSV) of the following information: The alpha below are bullets
- License(s) in noted profession(s)
- Board Certification, if applicable
- Education at highest level and Training
- Sanction activity, restrictions on license (limitations on scope of practice)
- Medicaid/Medicare Sanctions
- NPDB & HIPDB
- After the PSV is complete, applications are forwarded to the BCBSWY Credentialing Committee for approval (or disapproval).
- Once a credentialing determination has been made regarding an application submitted by a provider, BCBSWY notifies the provider.
If Approved
The provider is sent an approval notification letter that includes information on the preparation of their contract, website link to the Provider orientation materials, and contact information for the Provider Relations department to seek guidance or technical assistance as needed.
If Denied
A provider is sent a denial notification letter as well as contact information for the BSBSWY staff to address questions.
Who can I contact for assistance?
Our Provider Relations staff is available to answer questions about the credentialing process. You may contact us by email at [email protected] or by calling 888-666-5188.
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Credentialing
ACA Accreditation
Federal guidelines require that insurance plans become accredited in order to be able to offer Affordable Care Act (ACA) compliant plans.
Blue Cross Blue Shield of Wyoming has received Health Plan with Health Insurance Marketplace Accreditation from URAC. URAC accreditation requires that all providers be fully credentialed if they participate in our network(s).
What You Need to Know about Credentialing
You will receive the credentialing application from BCBSWY via email. Please read the application thoroughly and complete all sections. The following tips will ensure that the application is complete and reduce delays in processing.
- Make sure work history is completed using month and year. Be sure to address any gaps in your work history.
- Any malpractice claims need to be disclosed and outcomes identified.
- If you have a DEA Certificate and Wyoming Controlled Substance Registration, include this information in the appropriate section of the application.
Any personal information gathered during this process (i.e. personal emails, addresses, telephone numbers, etc.) will be used solely for credentialing purposes.
If you are a new provider or adding a new provider to the BCBSWY network, participation with BCBSWY cannot be dated prior to approval of your credentialing application. If you plan to see BCBSWY members before notification of your credentialing approval, you may request to be added to our claims processing system as a non-participating provider.
Providers will need to communicate with members about their non-participating status at the time of service. Please note that there is no benefit for preventive services if a member sees a non-participating provider and the out-of-pocket costs are higher for covered services. Claims for non-participating providers will pay to the member and balances are the responsibility of the provider and the member.
If you have any concerns or questions about this process, please feel free to contact the Provider Relations Department, at [email protected] or 888-666-5188.
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Prescription Drug Tools
Prior authorizations, drug lists and more
Prior Authorizations
For BCBSWY ID numbers beginning with ZRW, ZSD, ZYW or YWY.
For policies and forms for policy-holders with these 3-digit Alpha prefix go to: www.myprime.com > Forms > (Continue without Sign-On) > BCBS Wyoming > BCBSWY NetResults Formulary (or BCBSWY Standard Drug List)
For BCBSWY ID numbers beginning with ZSF, QWY or ZSK.
For policies and forms for policy-holders with these 3-digit Alpha prefix submit standardly via: CoverMyMeds
Formularies & Specialty Drug List
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Start Using Availity
Availity is BCBSWY’s secure Provider Portal to help you manage the care of your patients online with less paperwork, fewer faxes and reduced phone time.
- Verify your patients’ eligibility and benefits.
- Submit prior authorization requests.
- Get paid faster. File claims electronically.
- View claim status.
- View your electronic remittance advice (835) in real-time.
- Find information and updates on the BCBSWY payer space.
- No charge to use. HIPAA compliant.
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Partnership in Health
Patient care is your top priority – and ours. Together we’re committed to keeping Wyoming healthy and finding solutions for quality care.
Strong Relationships with Providers
As a health care provider, you have a direct impact on the satisfaction of our members and the quality of our health benefit plans. Since 1945, we’ve built a partnership together that will continue to stand the test of time.
The Power of Blue
The BlueCard® Program enables members of one Blue Cross and Blue Shield (BCBS) Plan to obtain health care services while traveling or living in another BCBS Plan’s service area. The program links participating health care providers with independent BCBS Plans nationwide.
Beyond our own borders, the Blue Cross Blue Shield Global® Core program connects more than 170 countries and territories worldwide via an extensive electronic network for claims processing and reimbursement. Yet, participating providers have just one point of contact—Blue Cross Blue Shield of Wyoming.
Ways to help members stay healthy
Wellness and prevention are key to helping our members enjoy a healthier lifestyle. To help them along the way, we provide access to health and wellness tools, tips, and preventive benefits.
A strong local company
With a large geographical area and a relatively small population, we are in a unique position to meet the needs of the people who live and work in Wyoming.
- Strong and stable Wyoming-based company
- Active in Wyoming’s health care market since 1945
- Statewide leader in finding solutions to community health issues
- Focused on improving the health and quality of life for Wyoming people