Authorizations & Appeals

Request prior authorization and submit appeals

Sometimes you’ll need to get approval before providing certain services to your patients. The requirements and processes for authorization differ based on your patients’ coverage plans, which are outlined below.

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Provider Administration Manual

Prior Authorization Information

Prior authorization is required for certain procedures, services and medications, as well as for all inpatient admissions. The requirements and processes for authorization differ based on your patients’ coverage plans. For detailed information, please see the Provider Administration Manual related to their coverage.

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Prior Authorization Requests

You can submit prior authorization requests for all lines of business 24/7 at Availity.com

Authorizations & Appeals

Review services that require special approval

Commercial

The programs listed below have specific prior authorization requirements.

You can verify benefits and request prior authorization at Availity.com or by phone at 1-888-693-32111-888-693-3211. You may also go directly to eviCore’s self-service web portal at www.evicore.com.

You can verify benefits and request prior authorization at Availity.com or by phone at  1-888-693-32111-888-693-3211. You may also go directly to eviCore’s self-service web portal at www.evicore.com.

This includes: CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET and CPT.You can verify benefits and request prior authorization at Availity.com or by phone at 1-888-693-32111-888-693-3211 or by fax at 1-888-693-3210.

Musculoskeletal prior authorization is required for spinal surgery, joint surgery (hip, knee and shoulder) and pain management. You can request prior authorization at Availity.com or by fax at 1-866-747-0587.

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Authorization Policies and Process

Authorization Appeals Process

We’re committed to providing quality and cost effective health care services to our members. Our decisions are based only on existence of coverage and appropriateness of care.

Before beginning the reconsideration and appeals process, treating providers can request a Peer-to-Peer discussion with a doctor to review details of the member’s condition and care options.

Expedited Appeals are available for members who are at a more urgent risk for severe health issues without the previously requested care or service. You can request an expedited appeal by calling the prior authorization number for the plan that covers your patient.

Parts of our Authorization Appeals Process
Request a Reconsideration

If you disagree with a decision we’ve made or if you need to provide additional information that may affect the decision, please submit a Provider Reconsideration Form to us within 18 months of the initial denial.

PDF Icon | BCBS of TennesseeReconsideration Process Map

Appeal the Reconsideration

You may file a formal appeal by submitting a Provider Appeals Form to us. Please see this helpful guide with timelines for each line of business. If the reconsideration stated that the reconsideration decision was related to medical necessity, you may be directed to the Commercial Utilization Management Appeal Form.

PDF Icon | BCBS of TennesseeAppeals Process Map

Request Arbitration

You have the option to request binding arbitration if you’re not satisfied with the formal appeal decision. Please see the Provider Dispute Resolution Procedure or the Provider Administration Manual based on the plan that covers your patient.

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Looking for more information?

Find the details in our Utilization Management Guidelines.