Use Availity's electronic authorization tool to determine whether pre-authorization is required for a medical service and to submit your medical pre-authorization requests. There's no need to call or fax us; login to the Availity Provider Portal to inquire and submit a request. It's quicker and more convenient for you.
Use the tool to:
- Find out immediately if a procedure code or level of care requires pre-authorization. Enter information and the tool will let you know if pre-authorization is required.
- If pre-authorization is required, continue and submit your request quickly and easily. You'll get confirmation of receipt and the status immediately.
- Check the status of pre-authorization requests you have submitted via the electronic authorization tool using the Auth/Referral Dashboard. Some of your requests may be approved the same day!
Our current pre-authorization requirements, guidelines and timeframes remain the same. Note: Contact the appropriate vendor to pre-authorize pharmacy (including injection or infusion), physical medicine, sleep medicine or radiology services. See which services cannot be authorized via this tool below.
Dental providers: Continue to submit dental predeterminations on the Availity Portal: Claims & Payments>Dental Claim>Claim Type: Predetermination. Our response will be sent to you via letter. Note: Predeterminations cannot be viewed on the Availity Portal.
Check the status of pre-authorization requests you have submitted or have been named in via the electronic authorization tool using the Auth/Referral Dashboard. Some of your requests may be approved the same day!
- Facilities and service providers can check the status of any pre-authorization requests submitted on the Availity Portal (on which they are named). Service providers may include primary care providers (PCPs), treating providers or admitting, attending and operating providers, in addition to facilities and independent laboratories.
- Providers can identify what episode of care is being requested for home health care pre-authorizations for Medicare Advantage members:
- First episode of care (which doesn't require pre-authorization)
- Subsequent episode of care (all of which do require pre-authorization)
The drop-down list is required and will appear only when Home Health Care is selected as the service type. Simply select whether the home health care is the first episode of care or a subsequent episode.
Pre-authorization and benefits check
The authorization tool will let you know, before submitting the request, whether the service or inpatient level of care is:
- Excluded from coverage
- Doesn't need pre-authorization
- Needs pre-authorization by Regence
- Needs pre-authorization through a vendor partner (e.g., AIM or eviCore)
You'll receive an authorization response when your request is received. The response includes the certification/reference number and status. Print the response page or write down the certification/reference number for your records. This response page will not be accessible on the Availity Portal after you navigate away from the page; however, status of your request is available 24/7 on the Auth/Referral Dashboard.
Direct clinical information reviews (MCG Health)
For select CPT codes, the authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to the Availity Portal to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a pre-authorization request.
This applies to pre-authorizations for our group and Individual, Uniform Medical Plan (UMP) and Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members. It does not currently include Medicare Advantage pre-authorizations. View the services that may receive automated approval (PDF).
MCG Health technical specifications:
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Supporting clinical documentation that is pertinent to the pre-authorization should be attached to the request and may include:
- Chart notes
- Treatment history
- History and physical
- Laboratory/radiology/test results
- Current symptoms and/or functional impairments
The maximum file size is 60MB per document, and multiple documents up to 150MB. If the file size is larger and can't be separated, create a document with a note that the file will be faxed. Save the note as a PDF and attach it to the authorization request.
Checking the status of an electronic pre-authorization request online is easy, there is no need to call or fax! Use the Auth/Referral Dashboard to view:
- All request submitted, in-process or completed
- The status (e.g., approved, denied, pending review) of each submitted request, including the individual status for requested services and/or inpatient levels of care. Note: Requests for services that should be submitted to one of our vendor partners, will show as incomplete.
Just select: Patient Registration>Authorizations & Referrals>Auth/Referral Dashboard, then click the case to refresh it and view the current status and details.
Providers have told us they had a better user experience using this tool after completing the training.
Trainings are available in the Availity Learning Center: Help & Training>Get Trained>Catalog>Regence Authorization Submission and Auth/Referral Dashboard - On-Demand.
Note: A quick reference guide is available in the content section after you enroll in the authorization training. It includes instructions and screen shots to help walk you through the electronic authorization process.
Which pre-authorization requests can be submitted via this tool?
Electronic authorization requests and associated clinical documentation can be submitted for all medical pre-authorizations reviewed by Regence for the following Regence members:
- Group and Individual
- BCBS FEP
- Medicare Advantage, except pre-service organization determinations which should be submitted using the current process
What's not included
The following should not be submitted as an electronic authorization:
- Pre-authorization of services reviewed by our vendor partners (AIM and eviCore); follow the current process
- Pre-authorization requests for pharmacy, as well as injections and infusions that may be covered under the member's medical benefit. Review our pharmacy pre-authorization information and follow the current process of submitting these through CoverMyMeds
- Referrals; no change to the current process
- Retro authorizations; no change to the current process
- Pre-authorizations for members in the BlueCard Program; follow the current process
- Appeals of any kind, including but not limited to, pre-service and post-service reviews/appeals
- Admission, discharge and transfer information; continue to follow the current process of submitting them through PreManage or your current process
- Groups managed through our joint administration third‑party administrators (AmeriBen [AmeriBen Medical Management] and Zenith American Solutions [Innovative Care Management]); follow the current process
- Authorization requests for extensions; follow the current process and fax these requests to us directly. Note: This feature will be added to the electronic authorization tool later.