Blue Cross Blue Shield of Tennessee, a Blue Cross Blue Shield Association affiliate, is the largest health insurance provider in the state of Tennessee with a 44% market share of the private insurance marketplace. They also provide medicare and medicaid plans in Tennessee under the names TennCare and BlueCare Plus. It goes without saying that many addiction treatment patients in Tennessee carry Blue Cross Blue Shield of Tennessee plans. 

Today, we’ll examine what utilization management reviews are required of addiction treatment providers working with Blue Cross Blue Shield of Tennessee plans. Other terms for these types of reviews are: prior authorizations, prior auths, utilization reviews, pre-certifications, certifications and authorizations. Generally speaking, these terms usually all refer to the same concept: asking a payer if they’ll cover an episode of addiction treatment at your treatment facility or clinic before that treatment occurs. Other types of reviews, such as concurrent or retrospective reviews, take place during or after care has occurred. Today, we’ll focus on the reviews that take place before addiction treatment care is rendered. 

What Forms of Addiction Treatment, at What Levels of Care, Require Prior Authorization Utilization Reviews? It Depends.  

There are many different types of plans available at Blue Cross Blue Shield of Tennessee and each one has slightly different rules.

There are three basic types of plans at BCBST: commercial, medicaid and medicare plans. 

You can consult the Provider Manuals for each of these types of plans to learn more about how behavioral health care coverage and billing works at BCBST, but we will summarize here for the sake of convenience. 

What Addiction Treatment Levels of Care Require Prior Authorization Utilization Review At BCBST for Individual, Commercial, and/or Employer Plans?

The following addiction treatment episodes require prior authorization for commercial plans with Blue Cross Blue Shield of Tennessee: 

• Inpatient Substance Use Detoxification 

• Residential Detoxification

• Residential Treatment for Substance Use Disorder 

• Partial Hospitalization Programs for Substance Use Disorder

• Intensive Outpatient Programs (IOP) for Substance Use Disorder

• Applied Behavioral Analysis for Substance Use Disorder

Essentially, any addiction treatment that’s not standard outpatient care requires prior authorization. Additionally, all out-of-network behavioral healthcare - regardless of the level of care it involves - requires prior authorization at BCBST. 

If the episode of care is an emergency, you may obtain a behavioral health utilization review for prior authorization 24 hours a day, 7 days a week from BCBST Utilization Management team. This emergency authorization can be done up to two days after care has begun. 

What Addiction Treatment Levels of Care Require Prior Authorization Utilization Review At BCBST for TennCare Patients?

The following episodes of addiction treatment care require prior authorization with Blue Cross Blue Shield of Tennessee’s TennCare program members: 

• “Inpatient” 

• “Substance Use Disorder” 

• “Subacute hospital” 

• Detox

Compared with the more precise terms used in the provider manual for the commercial plans at BCBST, the list of addiction treatment levels of care that require prior authorization for TennCare is pretty vague. Does this mean that all treatments at all levels of care for “substance use disorder” - which is a diagnosis, not a treatment - require prior authorization? The TennCare Provider Manual does not make this very clear. 

What Addiction Treatment Levels of Care Require Prior Authorization Utilization Review At BCBST for BlueCare Plus Patients?

Of all the types of plans available at BCBST, BlueCare Plus plans are the least restrictive in terms of prior authorization requirements for addiction treatment. 

The only addiction treatment levels of care that require prior authorization at BlueCare Plus are:

• Inpatient (detox)

• Residential substance use services 

Specifically, partial hospitalization programs, IOP programs and outpatient programs do not require prior authorization with BlueCare Plus. 

Need Help Understanding Review Requirements for Addiction Treatment at Blue Cross Blue Shield of Tennessee? We Can Help.

BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States. 

Even better, we’re not health care generalists.  We only work for behavioral health providers like you.

Let our team of specialists handle it all: 

• Verification of Benefits 

• Utilization Review 

• Billing and Collections 

• Patient Responsibility

• Denials and Appeals 

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.