Blue cross blue shield prior authorization form pdf

Q: What is a letter of prior authorization?

A prior authorization (PA), sometimes referred to as a pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure.

Q: Why is my insurance asking for a prior authorization?

Prior authorization (also called preauthorization” and precertification”) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered.

Certain services require prior review and certification from Blue Cross NC before they can be covered by your health insurance plan.

Table of Contents Show

Responsibility for Requesting Prior Review and Certification
For In-Network Providers
For Out-of-Network Providers
Why is prior review and certification necessary?
What types of procedures may require prior review and certification?
How can my provider request prior review and certification?
Prior authorization requirements for out-of-area Blue Plan members
How do I submit a prior authorization to availity?
What is a letter of prior authorization?
Does Blue Cross Blue Shield of Michigan require prior authorization?
Why is my insurance asking for a prior authorization?

Responsibility for Requesting Prior Review and Certification

For In-Network Providers

North Carolina providers or specialists in the Blue Cross NC network will request prior review for you. You may want to check with your health care provider to make sure that prior review was obtained before you have the service or procedure in question.

For Out-of-Network Providers

You are responsible for ensuring that out-of-network doctors have requested prior review and certification from Blue Cross NC before the service is performed. The physician or her office should request the review from Blue Cross NC. This also applies to BlueCard® providers (out of state providers who contract with another Blue Cross Blue Shield plan) outside of North Carolina. Your Benefit Booklet has more information about prior review and certification that is specific to your policy.

Prior review and certification is also known as:

Prior plan approval
Prior authorization
Prospective review
Certification
Precertification

In case of emergency, prior review and certification is NOT required. Blue Cross NC should be notified of an urgent or emergency admission by the second business day of the admission.

Prior review and Certification Code list:

This list is provided for member information only. It is a provider tool and is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the following quarter.

Prior Review and Certification Code List

Why is prior review and certification necessary?

Prior review and certification ensures that:

Your benefits cover the service in question
The service is medically necessary according to Blue Cross NC medical policy
The service is performed in the right health care setting
The provider is correctly identified as in- or out-of-network
Special medical circumstances are identified that require specific types of review and follow-up

Note: Blue Cross NC may certify a service received out-of-network at the in-network benefit level if the service is not reasonably available in-network or if there is a continuity of care issue.

What types of procedures may require prior review and certification?

Whether prior review and certification is required may depend on your Blue Cross NC benefit plan. Always check your Benefit Booklet for specific information about your plan. The following procedures typically require prior review and certification:,

Inpatient admissions (with the exception of maternity admissions) — elective, planned in advance or not related to an emergency.
Inpatient maternity stays longer than 48 hours after vaginal delivery or 96 hours after a C-section
Private duty nursing, skilled nursing facility, acute rehabilitation admissions (short-term inpatient recovery), home health care (including nursing and some home infusion).
Services performed by an out-of-network or non-BlueCard® out-of-state health care provider
Air ambulance services (emergency air ambulance does not require prior review)
Certain durable medical equipment (DME)
Transplants — solid organ (e.g. liver) or bone marrow/stem cell
Surgery and/or outpatient procedures

How can my provider request prior review and certification?

Your health care provider can use any of the following ways to request prior review and certification:

By phone: Blue Cross NC Utilization Management at 1-800-672-7897 Monday to Friday, 8 a.m. — 5 p.m. ET
By fax: Request form

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Prior authorization requirements for out-of-area Blue Plan members

Find medical policy and general prior authorization requirements for your patients who are covered by an out-of-area Blue Plan.

Find requirements

How do I submit a prior authorization to availity?

How to access and use Availity Authorizations:.

Select Patient Registration menu option, choose Authorizations & Referrals, then Authorizations*.

Select Payer BCBSOK, then choose your organization..

Select a Request Type and start request..

Review and submit your request..

What is a letter of prior authorization?

A prior authorization (PA), sometimes referred to as a “pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure.

Does Blue Cross Blue Shield of Michigan require prior authorization?

Authorization Requirements Authorization is required for Medicare Plus Blue PPO and PPO members who reside in Michigan. We recommend that the physician office submitting the request have the following information available: • Member name, date of birth, plan name and plan ID number.

Why is my insurance asking for a prior authorization?

Prior authorization (also called “preauthorization” and “precertification”) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered.

blue cross blue shield prior authorization form pdf