06/16/2022
Clinical Record Submission Update for Online Prior Authorization Requests
Starting June 18, 2022, the Availity® Essentials Authorizations & Referrals tool will require you to submit clinical attachments only when supporting documentation is necessary for determination. If the option to add attachments is not available during your submission, then clinicals are not required. Additionally, there’s no need to fax clinicals for your requested submission.
Clinical Record Submission Tips
The following information provides tips to enhance the clinical review process resulting in improved turn-around times for authorization determinations:
- Initial Acute Inpatient Authorization Request – Submit clinical documentation which may include tests, labs, and/or diagnostic results to support an inpatient stay meeting medical necessity when noted online via Availity to Blue Cross and Blue Shield of Texas (BCBSTX) or your preferred web vendor.
- Concurrent/Extension Authorization Request – If an extension is needed, please submit clinical documentation on or before the last authorized day or when requested by BCBSTX or your preferred web vendor.
Please do not resubmit clinical information. If clinicals are needed, BCBSTX will notify the submitting provider within 24 to 72 hours in one or more of the following ways:
- Call from the utilization management team
- Fax or letter regarding the determination or
- Check Availity or your preferred web vendor for real time determination status updates
Efficiently Submit Clinical Records
Submitting a prior authorization request utilizing Availity Authorizations & Referrals is efficient, offers the ability to verify status of decisions and provides real time online 24/7 access status. Register for Availity Essentials and get timesaving access at no charge. If you need registration assistance, contact Availity Client Services at 1-800- 282-4548. If you are already a registered Availity user, you do not need to re-register.
Remember to submit clinical documentation only:
- If noted on Availity as an initial request/prior authorization/referral need
- If you are requesting or there is a need for a clinical extensions/concurrent review
- If BCBSTX is requesting additional clinical information
- All clinicals must support the request
How to Access and Use Availity Authorizations & Referrals:
- Log in to Availity Essentials
- Select Patient Registration menu option, choose Authorizations & Referrals, then Authorizations
- Choose your organization, then select Payer BCBSTX or BCBSTX Medicaid
- Select a Request Type, start request and only submit clinical when required
- Review and submit your request
For more information, refer to the Authorizations User Guide. Providers who do not have online access can call the prior authorization number on back of member ID Card.
Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate or contract of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.