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.
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.
|Step||Perform the service and submit the claim (after you’ve confirmed you have an authorization on file for the service).|
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:
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.
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.
|Medical pre-authorizations and referrals||1-800-327-6716|
|Behavioral health authorizations||1-800-524-4010|
Medical pre-authorizations and referrals:
|Emergent Inpatient Notification||1-866-577-9678|
If we request additional clinical:
|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|
|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|
|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|