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Prior Authorization Overview

We review certain service and medication requests 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 an eTool like Authorization Manager or ConnectCenter to determine whether a referral or authorization is required for a specific service. Learn about our eTools.

Once you’ve checked member benefits and eligibility, our Inpatient Only List can help you in making level of care determinations. Please also refer to our medical policies.

 Inpatient Only List January 2024 (commercial members)

Step Submit your authorization request (see submission tips below).
Step Check the status of your authorization request.
  • Use Authorization Manager. For instructions, download our User Guide.
  • Receive notifications by fax by enrolling in our Automatic Fax-Back Program. This program is our automated fax process for faxing individual decision letters to enrolled providers. Once enrolled, you will receive a fax notification each time a member’s case is approved or denied in our system. To enroll in this program, please complete and return our Automatic Fax-Back Program: Request Form.
Step Perform the service and submit the claim (after you’ve confirmed you have an authorization on file for the service).
Submitting authorization requests

Either the primary care provider or the designated specialist (with an open referral from the primary care provider, 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.

For Please
Level of care authorization upon admission, concurrent reviews, and transfers between facilities for premature and medically complex infants in the NICU Contact ProgenyHealth:
  • By phone at 1-888-832-2006 and select the prompt for level of care authorization or to speak to a physician advisor for a peer-to-peer discussion
  • By secure fax at: 1-866-303-5749
Inpatient and outpatient medical and behavioral health authorization requests
278 transactions Refer to our Direct Connection page for more information
Federal Employee Program members Contact Ancillary Services at 1-800-451-8124 for FEP specific benefit           
Fax or mailed authorization requests Use Mass Collaborative's Prior Authorization Request Forms
  • Other forms are in our Forms Library. Click the left-margin link, "Authorization".
Medication or home infusion therapy requests Go to our Pharmacy page
  • Forms are also in our Forms Library. Click the left-margin link, "Authorization - Pharmacy"
BlueCard Members’ pre-service review (for out-of-area members or members of another Blue Plan) Use the Pre-service Review for BlueCard Members tool. Or call 1-800-676-BLUE.
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


Emergent Inpatient Notification 1-866-577-9678

If we request additional clinical:

  • Concurrent review



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



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