CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Joint and Spine Authorization Request Form / Coverage Criteria

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A payer intake and authorization form for joint and spine procedures used by providers to request utilization management review from Blue Cross Blue Shield Tennessee; applies to providers submitting preauthorization requests for joint and spine surgeries and related procedures for BCBSTN members.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyJoint and Spine Authorization Request Form / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed form with required procedure and diagnosis codes plus supporting medical records (imaging, office notes, prior conservative treatments) to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form used for joint and spine authorization

866-747-0586Utilization Management local phone

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CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Joint and Spine Authorization Request Form / Coverage Criteria

Customize your policy alerts

Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyJoint and Spine Authorization Request Form / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed form with required procedure and diagnosis codes plus supporting medical records (imaging, office notes, prior conservative treatments) to request authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form used for joint and spine authorization

866-747-0586Utilization Management local phone

Coverage Criteria and Authorization Intake

Authorization intake data

Authorization requests will be reviewed when the following information is provided

Required submission elements: Completed Joint and Spine Authorization Request form; member/patient information (including height, weight, BMI); rendering provider and facility details (facility NPI, contact phone, physical address, contact fax); requested procedure and anticipated date of service; CPT/HCPCS or ICD procedure code(s); primary and any additional diagnosis code(s); comorbidities (diabetes with A1C, hypertension, prior cardiac event, congestive heart failure, COPD, dialysis, renal failure, ascites, steroid use, disseminated cancer); Activities of Daily Living (ADL) functional status; psychosocial/substance use issues (including current smoker within past 12 months); planned use of allograft/autograft/BMP/stem cells or other products; co-surgeon or assistant details (type of assistant); vendor/product/manufacturer information (vendor, product name/type, manufacturer, product line); CPT 20930 tissue type if requested; supporting medical records (imaging, office visit notes, documentation of attempted conservative treatments and other pertinent clinical records)

Missing elements or supporting records may delay review or result in denial

This intake form is a tool to collect clinical and administrative information for preauthorization review and does not itself authorize the requested procedures. Providers must submit the completed form along with all required supporting documentation; incomplete or missing documentation may result in determination delays or denials.

Procedure and Diagnosis Coding

Procedure and diagnosis codes (provider-supplied)mixed

CPT/HCPCS or ICD Procedure Code(s)

field on form — providers must supply the applicable procedure codes

Diagnosis codes (provider-supplied)ICD-10

Primary Diagnosis code	field on form — provider must supply primary diagnosis
Additional Diagnosis code(s)	field on form — provider must supply any additional diagnoses

Referenced CPT exampleCPT

20930

CPT 20930 referenced on form — if requested indicate tissue type

inv-06: BMI

Field capturedPatient's BMI (numeric field) captured on the intake form

Use in reviewBMI is collected as part of comorbidity and risk factor data for utilization management review

Provider Submission Requirements and Documentation

Prior Authorization

Provide procedure and diagnosis codes on request

Include the requested procedure code(s) and diagnosis code(s) on the authorization request: supply CPT/HCPCS or ICD procedure code(s), the primary diagnosis code and any additional diagnosis code(s), plus the anticipated date of service and facility information.

CPT/HCPCS or ICD Procedure Code(s)
Primary Diagnosis code
Additional Diagnosis code(s)
Anticipated date of service
Facility information (Facility NPI, contact phone, address, fax)

Note

Complete all required intake form fields

Submit the completed intake form with all requested administrative and clinical fields filled (facility and provider contact details, anticipated date of service, BMI, comorbidities, ADL status, and vendor/product information when applicable).

Policy Background

The form gathers the clinical and administrative details necessary for utilization management review of joint and spine procedures, including patient comorbidities, functional status, planned implants or biologics, BMI, Activities of Daily Living (ADL) status, and whether assistants, grafts, or other products will be used. This information, together with supporting medical records (imaging, office visit notes, and documentation of prior conservative treatments), informs the authorization decision.

Definitions and Functional Status

inv-12: ADL functional status

ADL optionsIndependent; Partially dependent; Totally dependent

PurposeCollected to inform utilization management review of functional status and surgical risk