Follow Centers for Medicare & Medicaid Services Guidelines for Appointment Wait Time Standards

Ensure timely access to care for our members by following CMS guidelines for appointment wait time standards for behavioral health services, routine primary care and non‑urgent specialty care.

Learn How to Submit Photos to Support Utilization Management Requests

Use our electronic processes to submit photos to support prior authorization and recommended clinical review requests. Secured email and online options are preferred instead of faxing photocopies.

Review Billing Guidelines for Laboratory Claims for Efficient Processing

To guard against fraud, waste and abuse and facilitate claims processing, review our guidelines and tips on submitting independent clinical laboratory claims.

Avoid Denials of Long‑Term Care Claims with Help from a New Resource

We have a new resource to help you avoid common billing errors when submitting long‑term care claims for members of our Blue Cross Community Health Plans^SM.

Accurate Category II Codes May Help Identify Gaps in Care

Using the proper Current Procedural Terminology (CPT^®) Category II codes on claims can help streamline your administrative processes and ensure gaps in care are closed. We developed a coding reference for several quality measures that you can access in Availity^® Essentials.

Catch Up with Our Provider Network Consultants and Hot Topics

Our PNCs host monthly Provider Hot Topics webinars to keep you in the loop on upcoming initiatives and network updates. See highlights from recent sessions and register now for the next webinar on Dec. 12, 2024.

Cultural Awareness Webinars: Earn No‑Cost Continuing Education Credit

We offer a suite of self‑guided courses that provide cultural awareness training and continuing education credit. Webinars include chronic disease management and improving adherence in diverse populations.

Explore Learning Opportunities

We offer free webinars and workshops for providers who participate in our networks. Sessions include required training for Medicaid providers and coding for hematological disorders.

Funds to Be Recouped on Some Medicare Advantage Hospital and Ancillary Claims

We recently identified that some Medicare Advantage claims were paid incorrectly to hospitals and ancillary providers. You’ll receive a letter if you have any impacted claims. Learn more about our recoupment process.

Prior Authorization Changes for Government Programs

Effective Jan. 1, 2025, we’re changing prior authorization requirements for members of Blue Cross Medicare Advantage (PPO)^SM, BCCHP^SM and Blue Cross Community MMAI (Medicare‑Medicaid Plan)^SM.

Contracted Independent Labs: We May Be Contacting You to Initiate the Credentialing Process

We’re requiring all independent labs to undergo credentialing and recredentialing for the following networks: PPO, Blue Choice PPO^SM, Blue Cross Medicare Advantage (PPO) and Blue Cross Medicare Advantage (HMO)^SM. Learn what documents contracted independent labs must complete upon request for continued network participation.

Preferred Drugs to Be Recommended Through Enhanced Prior Authorization

When submitting prior authorization requests for certain drugs, you’ll receive recommendations for comparable preferred drugs, as of Jan. 1, 2025. This process can improve access to more affordable care for our commercial non‑HMO members.

Pharmacy Program Quarterly Update – Part 1

Some changes were made to our drug lists, including revisions, exclusions, dispensing limits and utilization management changes. Learn about these and other pharmacy program updates.

Prior Authorization Changes

Learn about changes to the standard prior authorization programs. They impact our members who have prescription drug benefits administered by Prime Therapeutics.

• Effective Jan. 1, 2025

• Effective Jan. 15, 2025