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Prior Authorization Overview

We review certain inpatient and outpatient services to determine if they are medically necessary and appropriate for the member. If we determine that the services are medically necessary, we send an approval—or authorization—in writing to the member, primary care provider (PCP), the treating physician, and the facility, if applicable, to let them know that we have approved the services.

When a request for service is not approved, we notify the PCP* and the member.

*When the member has a PCP.

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Authorization steps

Before performing a service that requires an authorization, you should take these steps:

Step Use a tool like Online Services() to determine whether a referral or authorization is required for a specific service.
Once you’ve checked member benefits and eligibility, our Outpatient & Surgical Day Care List can help you in making level of care determinations. If you are performing a procedure on this list in an outpatient setting, no prior authorization is required, unless required by medical policy.

Step Submit your authorization request (see submission tips below).
Step Check the status of your authorization request.
  • Receive notifications by fax. We share weekly inpatient and outpatient notification reports with PCPs, referring physicians, admitting facilities, and other providers. The report shows the admission and/or service authorizations for your managed care members that were approved or denied for the week prior to the report dates. To enroll in our automated fax-back program, please complete and return our Daily Notification Report Form.
  • Find real-time information online. Use Online Services() to check the status of your authorization request. For instructions, download our Quick Start Guide.
Step Perform the service and submit the claim (after you’ve confirmed you have an authorization on file for the service).
Tips for submitting authorization requests

Either the PCP or the designated specialist (with an open referral from the PCP, as applicable depending on the plan) can request authorization for outpatient services. If we have not provided approval for outpatient services that require authorization, the provider rendering the service is financially liable, unless the member has previously consented in writing to be billed.

You can initiate an authorization using:

  • Online Services() for initial authorization requests for home health care, nutritional counseling, physical therapy, occupational therapy, and speech therapy.
  • Direct Connection()
  • For Federal Employee Program members only: Contact Ancillary Services at 1-800-451-8124 for FEP-specific benefit
  • Change Healthcare’s InterQual SmartSheets can be used for the submission of authorization requests for certain back surgeries and hysterectomies.
    • On our InterQual Criteria & SmartSheets() page, scroll down to use the interactive tool, InterQual Level of Care Criteria. More information is in our Authorization Quick Tip.
  • The Standardized Prior Authorization Request Form.
    • Other forms are in our Forms Library. Click the left-margin link, "Authorization".
  • The Pre-service Review for BlueCard Members tool() for out-of-area members, or by calling 1-800-676-BLUE.

Home health services, nutritional counseling, and short-term rehabilitation
When our guidelines are followed, we automatically approve initial authorization requests for these services for our managed care members. (For our guidelines, refer to our Outpatient Rehabilitation Therapy and Home Health Care pages. For nutritional counseling, refer to our Authorization Quick Tip.)

Authorization requests for services that are automatically approved should be submitted prior to the date of service. In those cases when the PCP or designated specialist cannot enter the authorization in advance of the service, it can be submitted up to 90 days after the date of service. The extended submission window is for those rare occasions.

Submit all retroactive auto-approved authorizations via an electronic technology. Enter the actual date of service as the start date.

Note: There may be exceptions to this policy listed in your Provider Agreements.

Contact Us

We urge you to check on the status of your authorization requests electronically. If you have questions once you’ve taken this step, you may reach us at the phone and fax numbers indicated below.

Phone information

For: Call:
Medical pre-authorizations and referrals 1-800-327-6716
Behavioral health authorizations 1-800-524-4010

 

Fax information

For: Fax:

Medical pre-authorizations and referrals:

  • Inpatient authorizations
  • Outpatient authorizations
  • Medical Policy
  • Referrals

1-888-282-0780

Emergent Inpatient Notification 1-866-577-9678

If we request additional clinical:

  • Concurrent review

1-888-282-1321

 

Outpatient Physical, Occupational and Speech Therapy authorizations 1-866-577-9901
InterQual Smart Sheets TM Surgical forms 1-888-641-1375
IVF authorizations and referrals 1-800-836-1112
Skilled nursing facility, rehabilitation hospital, inpatient hospice and respite 1-888-641-5330

Behavioral Health:

  • Inpatient notifications
  • Outpatient pre-authorizations and treatment request forms
  • Neuropsychological testing
  • Substance use authorizations
  • Referrals

1-888-641-5199

 

Federal Employee Program Plans  
Federal Employee Plan: Authorizations and InterQual Smart Sheets TM Surgical Forms 1-888-282-1315
Federal Employee Plan: Additional requested clinical information 1-866-577-9682
Medicare Plans  
Medex®' : Authorizations and referrals 617-246-4210
Medicare Advantage: Authorizations and referrals 1-800-447-2994
Medicare Advantage: Additional requested clinical information 1-866-577-9682
Medicare Advantage: Skilled nursing facility and rehabilitation hospital 1-800-205-8885
Blue Cross Blue Shield of Massachusetts Employees  
BCBSMA employees: authorizations, referrals and InterQual Smart Sheets TM Surgical forms 617-246-4299
BCBSMA employees: behavioral health/substance use authorizations and neuropsychological testing 1-888-608-3693