Regence BlueCross BlueShield of Oregon Prior Authorization Form: A Step-by-Step Guide

Introduction

For healthcare providers in Oregon, securing prior authorizations from Regence BlueCross BlueShield of Oregon (Regence Oregon) is essential to ensure that patients receive necessary medical services covered under their health plans. Understanding and adhering to the authorization process can prevent delays, denials, and potential financial liabilities. This guide provides a detailed overview of the steps involved in obtaining prior authorizations, ensuring a smooth experience for both providers and patients.

What is Regence Oregon Prior Authorization?

Prior authorization is a process where certain medical services, procedures, or medications require approval from Regence Oregon before they are provided. This ensures that the proposed care is medically necessary and aligns with the patient's coverage.

Services Typically Requiring Prior Authorization

• Inpatient Admissions: Non-emergency hospital stays.
• Outpatient Procedures: Certain surgeries and interventions.
• Advanced Imaging: MRI, CT scans, and PET scans.
• Durable Medical Equipment (DME): Specific medical equipment and supplies.
• Specialty Medications: High-cost or specialized drugs.

For a comprehensive list, refer to Regence Oregon's Commercial Pre-authorization List.

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Step-by-Step Guide to Obtaining Prior Authorization

1. Verify Patient Eligibility and Benefits

Before initiating any procedure, confirm the patient's eligibility and benefits:

• Online: Use the Availity Essentials portal to check eligibility and determine if prior authorization is required.
• By Phone: Contact Regence Oregon's customer service using the number on the member's ID card

2. Determine If Prior Authorization Is Required

Not all services require prior authorization. Utilize the electronic authorization tool available on the Availity Essentials portal to:

• Check if a procedure code requires authorization.
• Submit authorization requests.
• View determination letters.‍

The Regence tool provides immediate feedback on authorization requirements.

3. Gather Necessary Information

Collect the following details to ensure a complete authorization request:

• Patient Information: Full name, date of birth, Regence Oregon member ID, and group number.
• Provider Details: Name, National Provider Identifier (NPI), address, and contact information.
• Service Details: CPT/HCPCS codes, diagnosis codes (ICD-10), proposed date of service, and location.
• Clinical Documentation: Relevant medical records, lab results, imaging studies, and notes supporting medical necessity.

4. Submit the Prior Authorization Request

Depending on the service, choose the appropriate submission method:

• Electronic Submission (Preferred): Through the Availity Essentials portal. This method offers real-time responses and status updates.
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• Fax Submission: For services managed by specific vendors, refer to the appropriate fax numbers provided by Regence Oregon.
• Phone Submission: For urgent requests, contact Regence Oregon's utilization management department directly.

5. Monitor the Authorization Status

After submission, it's crucial to track the status of your request:

• Online: Use the Availity Essentials portal to monitor real-time updates.
• By Phone: Reach out to Regence Oregon's customer service for status inquiries.

6. Respond Promptly to Additional Information Requests

If Regence Oregon requests further documentation or clarification:

• Provide the necessary information without delay to prevent processing setbacks.
• Ensure all supplementary documents are comprehensive and pertinent to the request.

7. Receive and Communicate the Determination

Once a decision is made:

• Approval: Proceed with scheduling and performing the service.
• Denial: Review the denial reasons, discuss alternatives with the patient, or consider initiating an appeal if justified.

For appeal procedures, consult Regence Oregon's Medical Policy and Pre-certification/Pre-authorization Information.

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Special Considerations

1. Medicare Advantage Members

For services involving Medicare Advantage members:

• Pre-authorization Requirements: Review the Medicare Pre-authorization List for specific services.
• Submission Process: Utilize the designated forms and follow the outlined procedures to ensure compliance.

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2. Pharmacy Services

Certain medications may necessitate prior authorization:

• Submission: Use CoverMyMeds for pharmacy pre-authorization requests.
• Guidelines: Refer to Regence Oregon's Pharmacy Pre-authorization page for detailed information.

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