Prior authorization reviews, known in the Thomas/Love Settlement as Precertification, is the process which BlueCross BlueShield of Tennessee (BCBST) requires for verifying medical necessity of certain treatments.  This process helps to ensure Members receive the appropriate level of care in the appropriate setting.

Requests for tests, procedures, or services requiring prior authorization must contain adequate information for review.  The following list provides an overview of the standard services or supplies, as provided by a member’s benefit plan that require a prior authorization:

• Inpatient Services
• High Tech Imaging
• Durable Medical Equipment
• Home Health Services
• Rehabilitative Services
• Endometrial Ablation

Types of reviews required are subject to change. Providers will be notified of any changes in review requirements through quarterly updates to the BlueCross BlueShield of Tennessee Provider Administration Manual, BlueAlert monthly provider newsletter, and other BlueCross BlueShield of Tennessee communications, including the BlueCross BlueShield of Tennessee company Web site www.bcbst.com

For more information regarding prior authorization and/or medical record submission please refer to the Provider Administration Manual.  http://www.bcbst.com/providers/manuals/bcbstPAM.pdf