specialty pharmacy submission - bcbst.com

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Specialty Pharmacy Submission

BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield AssociationBlueCross, BlueShield, BlueCare and the cross and shield symbols are all registered marks of the BlueCross BlueShield Association,

an Association of Independent BlueCross and BlueShield PlansCPT® is a registered trademark of the American Medical Association

This document has been classified as public information.

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Enter user ID and password to log on to the secure area of bcbst.com.

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Authorization SubmissionSpecialty Pharmacy Submission

Select “Commercial/BlueAdvantage/BlueCare®/TennCareSelect”to begin the authorization submission process.

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Choose “Commercial” to work with commercial plans.

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Special Pharmacy authorizations can be submitted online under “Authorization/Advance Determination Submission”

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Select “Specialty Pharmacy” to start the authorization process.

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Select a patient by entering the patient’s member ID number without the three-letter prefix, then select “Search.”

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Highlight correct patient and click.

Patient information will auto-populate

into the correct fields.

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Select the appropriate Specialty Pharmacy Procedure Code from the drop-down menu.

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Enter the Requesting Provider ID number, or search.

Servicing Provider ID is not required if same as the requesting provider.

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Search for Providers by entering ID, name or location then click “Search.”

A list of possible matches will becreated. Click the correct providerto auto-populate the authorization request.

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Specialty Pharmacy Authorizations cannotbe back-dated.

Reminder: •All fields with an asterisk must be completed. •ICD-9 codes should omit decimals.•Dates are in MM/DD/YY format.

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Select the appropriate options from drop-down menus.

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Milliman Care Guidelines Criteria is selected by default and is necessary to obtain immediate online authorization.

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Please note any pertinent patient co-morbidities/history here. You may also list additional diagnosis or procedure codes.

If Milliman Care Guidelines Criteria are not applied, supporting information is required here and the authorization will be pended for review.

When this screen is completed, choose “Continue.”

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When the screen is completed, a summary screen will be shown.Please review the information for accuracy and provider network status.

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If changes are needed, click “Back” to go back and correct the information. When all information is correct, click “Continue.”

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Apply Milliman Criteria

The system will list guidelines most closely associated with the diagnosis and procedure codes entered. If one is appropriate, click the box next to it

and select “Continue.”

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It is also possible to search for a guideline by selecting“Show All Guidelines” and “Search Guidelines.”

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Click “Show All Guidelines” to bring up a drill-down menu. Click on “+” to drill down to the appropriate guideline, then select the specific Specialty Drug.

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The “Search Guidelines” option will bring up a search screen and can be searched by ICD-9 or CPT® Code or by guideline description.

This example is being searched by description.Select “Search” after entering code or description.

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Select the appropriate guideline and click “Continue.”

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Select all that apply, then click “Continue.”

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A summary screen will show selected criteria.

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If the clinical information submitted meets criteria, an authorizationnumber will be given. Print this page for your records.

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If clinical information does not meet guidelines, submit any additional clinical information to be considered for review, then click “Finish.”

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Authorizations that are pended will generate a confirmation number. The confirmation number may be used to check status of the request online.

A nurse will call with the decision.

The Gold Card network (Blue Network K) cannot be used for Specialty Pharmacy.

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Click “Home” at the bottom of the page to return to the first screen.

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Questions?

specialty pharmacy submission - bcbst.com

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