Authorizations User Guide - BCBSIL

1 Authorizations User Guide via Availity Essentials Getting StartedJan. 2022 Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationBlue Cross , Blue Shield and the Cross and Shield Sy mbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Availity Administrator: Access must first be granted to users by going to My Account Dashboard Maintain User or Add User select roles authorization and referral Inquiry and authorization and referral Request. Authorizations is an online prior authorization tool in Availity Essentials that allows providers to submit inpatient admissions and select outpatient services handled by Blue Cross and Blue Shield of Illinois ( BCBSIL ). Using this tool increases administrative efficiencies by permitting users to access and verify status of requests, upload supporting clinical documentation, update requests, and obtain printable confirmation number for your records.

2 You must be a registered Availity user to access and utilize Authorizations . If you are not yet registered with Availity, complete the guided online registration at Availity, at no Reminder: Check eligibility and benefits online first to determine if the patient s policy requires prior authorization for the service and/or procedure code(s). To learn more about checking eligibility and benefits via Availity, refer to the Eligibility and Benefits User Guide Contents PageContentsPageContents1 Getti ng Sta rted 7 Add Rendering Provider (Step 3) 2 Expres s Entry Setup8 Add Attachments (Step 4) 3 Acces s ing Authorizations8 Review and Submit (Step 5) 4Pa yer a nd Request Type 9 Submi ssion Res ponse 4 Sta rt Auth (Step 1 Member I nfo) 9 Auth/ referral Dashboard 5 Sta rt Auth (Step 1 Reques ti ng Pr ovider )10 View and Update Requests 6 Add Service Information (Step 2) 10 & 11 Auth/ referral Inquiry 7 Add Ser vi c e Pr ovider (Step 3) 12 Submi ssion Ti ps Go to Avai litySel ec t Availity Essentials Login Enter User ID and PasswordSel ec t Log in Medical Record Requests from BCBSOK Express Entry Setup Associated information will return based on the NPI added.

3 The provider's name, address, phone and fax numbers may be changed by selecting Tips:Sel ec t Add Additional IdentifiersChoose Tax ID (EIN ) andSpecialty/Taxonomy from the drop-down menuEnter Tax ID a nd s el ect Specialty/TaxonomySel ec t SavePage2 of 12 Availity Administrators are encouraged to add Requesting, Rendering and Servicing provider information to Express Entry. This step will lessen the need for users to manually enter all required provider information in the authorization request. Sel ec tMy Providers from the navigation menuSel ec t Express EntryWithin Manage Express Entry, expand Add Provider Enter the Provider s NPISel ec t Add Provider Express Entry setup i s only available for Administrators and is also found in My Account Dashboard. Back to HomeAuthorizations User Guide via Availity Essentials Sel ec tPatient Registration from the navigation menuSel ec t Authorizations & ReferralsNext, c hoos e authorization Medical Record Requests from BCBSOK Accessing Authorizations ( BCBSIL )Quick Tip: Select A IM ( BCBSIL ) to start and submit authorization requests handled by AIM Specialty Health.

4 Page3 of 12 Back to HomeAuthorizations User Guide via Availity Essentials Quick Tip: Return to this page to access the Auth/ referral Inquiry and Auth/ referral Medical Record Requests from BCBSOK Sel ec t Organizat ionSel ec t BCBSILP ayer option*Choos e a Request Type: Inpatient authorization Outpatient AuthorizationSel ec t NextEnter the following Pat ient Informat ion: Member ID Relationship to Subscriber Pat ient First and L ast Name Patient Date of BirthPayer and Request TypeBCBSILBCBSILQ uick Tip: Only required fields will display. To view optional fields, select Show Optional )Start authorization *This payer option should be selected for all BCBSIL members, including Medicare Advantage and Illinois Tip: Choose Outpatient authorization to submi t Offi c e, Home and Outpatient services. Page 4 of 12 Back to HomeAuthorizations User Guide via Availity Essentials Medical Record Requests from BCBSOK 1)Start authorization (continued)Enter the fol l owing Requesting Provider i n f or mati on : Provider Type Name NPI Number Specialty / TaxonomySel ec t Next Address Cont act Name Contact Phone Number Contact Fax NumberMountain View Regional Hospital12345678902278G1100X General CareIllinois12345-0000 Quick Tips: Electronic Provider Access (EPA) is a tool that enables providers to initiate online pre-service reviews for out-of-area members and is available to all contracted BCBSIL providers who are registered Availity users.

5 If the member belongs to another Blues Plan, you will be re-directed to the other Plan s pre-service review landing page after Step 1 (Start an authorization ) i s complete. If the other Blues Plan does not utilize Availity, you will receive a message that you are being redirected to a third-party 5 of 12 Back to HomeQuick Tip: Use Selec t a Provider to quickly populate required provider information. Administrators can refer to page 2 for Express Entry setup User Guide via Availity Essentials Medical Record Requests from BCBSOK 2)Add Service InformationAdd the followingSe rvice Informat ion: Se rvice Type Place of Se rvice Admission Date Admission Type Quantity Quantity Type Diagnosis Code(s) Procedure Code(s) (if applicable)Sel ec t Next Quick Tip: Add up to 12 Diagnosis Code(s) and Procedure Code(s) by selecting Add another diagnosis code and Add another procedure code. 12/20/2021 Page 6 of 12 Back to HomeAuthorizations User Guide via Availity Essentials Medical Record Requests from BCBSOK 3)Service/Facility Provider InformationAdd the following Se rvice Provider information: First Name L ast Name NPI Number Address Add the following Rendering Provider information: First Name L ast Name NPI Number Address Sel ec t Next Quick Tip: As a reminder, use Selec t a Provider to quickly populate required provider information.

6 ILLINOISD OE, JOH N *123456789 0* 123 AN YW H ER E ST, SAM E PLAC E, IL 12345 JOHNDOE1234567890123 ANYW HERE STSAM E PLACE12345M OU N TAIN VIEW R EGION AL H OSPITAL*123456 78 9 1 * 1234 AN YW H ER E ST, SAM E PLAC E, IL 12345M OUNTAIN VIEW REGIONAL HOSPITAL12345678901234 ANYW HERE STSAM E PLACE12345 ILLINOISPage 7 of 12 Back to HomeAuthorizations User Guide via Availity Essentials Medical Record Requests from BCBSOK 4)Add AttachmentsSubmit all appropriate clinical documentation supporting your request prior to submission Sel ec t Add Filesto upload and attach the applicable documentation Sel ec t NextQuick Tips: If adding multiple files, do not click Nextuntil all applicable files have been attached. Users may add up to 10 attachments, with a total file size of 40MB. Accept files type of PDF (.pdf), TIFF (.tif), J PEG (.jpg), or XML (.xml ). ABC ClinicBCBSILPat ient5)Review and SubmitScroll down the prior authorization request preview screen, review the information entered for accuracy and make any necessary changes prior to submitting the requestI f the i nfor mation is c orr ect, s elec t SubmitQuick Tip: Select Back to Step to make changes prior to submitting 8 of 12 Back to HomeAuthorizations User Guide via Availity Essentials Quick Tip: Instructional messagingwill display for requests that pend and/or requests that cannot be submitted via Medical Record Requests from BCBSOK Submission ResponseAuthorization Responses will provide the Certification Number and St atusStatuswi l l display: Certified in Total (approved) Pended(for clinical review)Auth/ referral Dashboard Search for requests (by Patient Name, Certification Number, Member ID, Requesting Provider NPI) Check Status View and/or print Update requestsSel ec t the request card to vi ew authorization detailsQuick Tip.

7 By default, the Dashboard displays all requests submitted in the last 14 days and sorts most recent requests at top of the list. Quick Tip: Select New Request to start a new authorization from the LAc c es s the Auth/ referral Dashboard from the top of the authorization Response sc reen or fr om the Authorizations & referral pageAuth/ referral Dashboard a llows users to vi ew r equests s ubmitted to BCBSI L via Ava ility Us e the Dashboardto compl ete the fol lowing ta sks: Page 9 of 12 Back to HomeServi ce I n fo rmati o n2021-10-26 2021-11-0 2 Servi ce I n fo rmati o n2021-11-01 2021-11-3 0 Servi ce I n fo rmati o n2021-12-10 2021-12-2 4 Authorizations User Guide via Availity Essentials Medical Record Requests from BCBSOK View and Update RequestsAfter s el ec ting the request card, the following i nformation displays: Patient Information Certification Information Service Information Sel ec t Updateto r evi se applicable requests Quick Tip: Use the additional options to print, unfollow, or move items to trash.

8 BCBSI Medical Record Requests from BCBSOK Us eAuth/ referral Inquiryto view member-specific prior authorization requests previously submitted to BCBSILAc c es s the Auth/ referral Inquiry f r om the authorization & referral page Sel ec t Organizat ionSel ec t BCBSIL payer option*Choose a Request Type: Inpatient authorization Outpatient AuthorizationSel ec t NextBCBSILAuth/ referral Inquiry can be used to Requests set-up through an outside vendor. Requests initiated by phone. Requests submitted by a different provider organization. Auth/ referral Inquiry2021-20-12 2021-27-12 Page 10 of 12 Back to HomeAuthorizations User Guide via Availity Essentials *This payer option should be selected for all BCBSIL members, including Medicare Advantage and Illinois Inquiry (continued)Enter the following information: Member ID Relationship to Subscriber Date of Birth12/01/202112/31/2021 Requesting Provider NPI From Dat e To Dat ePage 11 of 12 Back to HomeQuick Tip: Enter Servic e Dates AND/ORAuthorization Certification number to locate the authorization request.

9 Authorizations User Guide via Availity Essentials Submission TipsHave questions or need additional education? Ema il the Provider Education sure to include your name, direct contact information & Tax ID or billing NPI. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronicinformation exchange services to medical professionals. Availity provides administrative services to BCBSIL . BCBSIL makes no endorsement, representations or wa rra nties regarding third party v endors and the products and serv ices they ing eligibility and/or benefit information is not a guarantee of pay ment. Benefits will be determined once a claim is receiv ed and will be based upon, among other things, the member s eligibility and the terms of the member s certificate of cov erage applicable on the date services were rendered. I f y ou hav e any questions, please call the number on the member s I D M Specialty Health is an independent medical benefits management company that prov ides utilization management serv ices for BCBSIL .

10 BCBSIL mak es no endorsement, representations or warranties regarding third party v endors and the products and serv ices they 12 of 12 Back to HomeRequested ServiceRequest TypeService TypePlace of TreatmentPartial Hospitalization for Behavioral Health and/or Substance Abuse Outpatient AuthorizationMH Mental HealthAI Substance Abuse52 Partial HospitalizationHome Health Care and Home Infusion TherapyOutpatient Authorization42 Home Health Care12 Home Note: Ensure the appropriate procedure code(s) for Home Health Care or Home Infusion Therapy are entered on the request. Skilled Nursing CareOutpatient AuthorizationAG Skilled Nursing Care12 HomePrivate Duty NursingOutpatient Authorization74 Private Duty Nursing12 Home Long Te rm Acute Ca reInpatient Authorization54 Long Term Care21 Inpatient Hospital Submission tips are listed below to further assist providers with submitting certain requests via the Authorizations tool. Authorizations User Guide via Availity Essentials