Provider Central

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. Outpatient & Surgical Day Care List January 2020 Outpatient & Surgical Day Care List November 2020
Step	Submit your authorization request (see submission tips below).
Step	Check the status of your authorization request. Use Authorization Manager() for your Medicare Advantage members. For instructions, download our Quick Start Guide. Use Online Services(). For instructions, download our Quick Start Guide. 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.
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:

• Online Services() for initial authorization requests for home health care, 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 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.)

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.

Phone information

Fax information