Blue Cross and Blue Shield of Tennessee Prior Authorization

Blue Cross and Blue Shield of Tennessee prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• Prior authorization requirements vary by line of business and service type. In the commercial provider manual, prior authorization is required before scheduled services or within 2 business days of emergent services; Medicare Advantage timing is noted as 24 hours or next business day. Requests can be submitted in Availity e-Health Services, by phone, or by fax using the applicable form. The manual also states all inpatient stays require prior authorization, and some outpatient procedures do as well. The provider site directs providers to Availity for prior authorization requests across lines of business.
• Requirements differ by plan and service; self-funded arrangements may differ from insured plans.
• Some outpatient services do not require prior authorization, but may require it if performed inpatient.
• The commercial manual states prior auth requirements are listed on bcbst.com and a prior-auth PDF; the exact service-level list should be checked before submission.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3

How to submit prior authorization requests

• Availity e-Health Services / Availity portal

• Phone

• Fax

• Submission resource 1

Information commonly required

• Member identification number and name
• Patient name and date of birth
• Practitioner name, provider number and/or NPI, address, telephone number, and caller name
• Facility/hospital name, provider number and/or NPI, address, telephone number, and caller name
• Procedure/operation to be performed, if applicable
• Diagnosis with supporting signs/symptoms
• Vital signs and abnormal lab results
• Elimination status
• Ambulatory status
• Hydration status
• Co-morbidities impacting the patient’s condition
• Complications
• Prognosis or expected length of stay
• Current medications
• Test results

Turnaround notes and caveats

• Authorization should be obtained prior to scheduled services or within 2 business days of emergent services.
• For requests needing additional information, if the requested information is not received by the end of the next calendar day, the request will be denied for lack of information.
• The manual notes a different timeframe for Medicare Advantage: 24 hours or next business day.
• Requirements differ by plan and service; self-funded arrangements may differ from insured plans.
• Some outpatient services do not require prior authorization, but may require it if performed inpatient.
• The commercial manual states prior auth requirements are listed on bcbst.com and a prior-auth PDF; the exact service-level list should be checked before submission.

Provider resources

• Manuals, Policies & Guidelines (official)
• Health Care Providers / Authorizations & Appeals (official)
• Coverage & Claims (official)
• Provider Contact Us (official)
• BlueCross BlueShield of Tennessee Provider Administration Manual (official)
• BlueCare Tennessee Provider Administration Manual (official)
• Claim Summary (official)
• Documents and Forms (official)

Sources