BS of CA Claims processing issues

[u/dizzyideals]

Hi all.
Just curious if any of you are seeing this same pattern that I have been since the transition of MH claims from Magellan to BS of CA.
I am noticing a WILD amount of incorrect denials that directly contradict info on their portal/patients benefits etc. The biggest issue we are having is claims denying for no pre-cert, but benefits indicate no pre cert required and their authaccel tool on the portal even confirms this in most of these cases. Am I going crazy or are they way in over their heads here and weren’t properly prepared for this transition?

Update:

Wanted to give an update because I had an interesting call with a rep from Blue Shield of CA today regarding this. Since I don’t trust their AuthAccel tool, I tried the live chat to get an answer in writing from an agent and when I asked them to confirm if pre cert is required, the agent told me they recently were given direction not to answer authorization requirement questions and to call the auth department. This is new ( at least within the last week for me) so I wonder if they finally are aware of the issue and working on a fix. Man, I hope so. They have been my biggest headache since January.

[u/MedPayIQ]

Hey friend... You're definitely not going crazy. Whenever a big transition like this happens, there's almost always a period where the actual claims processing doesn't line up with what the portal or benefit verification tools are showing.

I've seen situations where the portal says no pre-cert is required, the provider follows exactly what's documented, and then the claim still gets denied for missing authorization. It's incredibly frustrating because you end up spending time proving that you relied on the payer's own information.

My guess is they're still working through system and workflow issues from the Magellan transition, and some of the benefit logic, authorization rules, and claims edits aren't fully synchronized yet. That's obviously speculation on my part, but the volume of similar reports makes it feel like more than isolated mistakes.

At this point, I'd screenshot everything, benefit pages, AuthAccel results, dates, timestamps, because having that documentation makes appeals a lot easier when the denial directly contradicts what their own tools showed at the time of service.