At BlueCross BlueShield of Tennessee, we use prior authorization to help ensure the care and medications our members receive are safe, clinically appropriate, covered by their plan, and cost-effective. We’re joining our fellow Blue plans to make prior authorizations work better for everyone, and to share more information about our efforts.
First, let’s talk about why we use this advance approval process.
Why is prior authorization necessary, and how does it help?
Prior authorization is one of the tools we use to make coverage decisions rooted in evidence-based care. In doing so, we ensure that healthcare dollars are being spent on treatments that have been proven to work. This helps to prevent unnecessary and sometimes, dangerous treatments. By promoting evidence-based care, prior authorization also helps us balance access with affordability.
This process helps:
- identify the most cost-effective treatment option without compromising quality. Our board-certified doctors and nurses review key elements of each situation, taking into account that different settings charge different amounts for the same procedure and that drug companies encourage doctors to prescribe their brands.
- prevent redundant tests that can slow down care processes and overall treatment.
- avoid costly surprises by reviewing care, treatment, or devices to ensure they’re covered by your plan.
Of the millions of claims we process for care and prescription drugs each year, only about 3% of services and 5% of pharmacy treatments require prior authorization. And the vast majority of requests are approved. Members can check the status of their prior authorization through our BCBST mobile app. It’s important to know that emergency care is always covered and does not require prior authorization.
How we’re improving our process: fewer prior authorizations, delivered more quickly
We’re committed to:
- processing more requests in real-time when we have the necessary clinical information, and
- reducing the number of medical services and drugs that require prior authorization.
We’ll continue to focus our prior authorization efforts on treatments where the process can improve member outcomes or provide effective but lower-cost alternatives.
When this advanced approval is necessary, there will be fewer steps to submit a request – and providers will get a decision from our clinical teams faster. And if a request doesn’t meet the appropriate clinical criteria, we’ll point out covered benefits that members can discuss with their providers.
Health care coverage is one of the largest costs employers manage – and they are always asking us to help manage those costs.
By simplifying and accelerating prior authorization, we aim to reduce administrative burdens as we support affordability and improve access to effective care. We believe these efforts will ultimately bring greater clarity and peace of mind to those we serve.