Prior Auth Overview

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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 change requests	Indicate “level of care change request” on your cover sheet and fax the below information to us: Original authorization number Member name, date of birth, and ID number Level of care that you are requesting (inpatient or outpatient) Admit date (for inpatient) or start date (for outpatient) Name and NPI of MD and facility Facility address (if outside of Massachusetts) Diagnosis and CPT/HCPCS codes Supporting clinical Commercial (HMO, PPO, Indemnity): 1-866-577-9678 Federal Employee Program (FEP): 1-888-282-1315 Medicare: 1-800-447-2994
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	Use our eTool, Authorization Manager Use Carelon for certain genetic tests, high-technology radiology, outpatient cancer care, and sleep management services. Use Rapid Response System for chiropractic services Be sure to attach any additional necessary clinical documentation.
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. Be sure to submit any additional necessary clinical documentation. 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.

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

Behavioral Health (all plans)

For:	Fax:
Behavioral Health and Substance Use requests: Inpatient notifications Outpatient pre-authorizations and treatment request forms Neuropsychological testing Substance use authorizations	1-888-641-5199 for non-Blue Cross Blue Shield of Massachusetts (BCBSMA) employees 1-888-608-3693 for BCBSMA employees
Behavioral Health clinical	1-888-973-0727
Applied Behavior Analysis (ABA) requests	1-617-246-4281

For:

Fax:

Behavioral Health and Substance Use requests:

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

1-888-641-5199 for non-Blue Cross Blue Shield of Massachusetts (BCBSMA) employees

1-888-608-3693 for BCBSMA employees

Behavioral Health clinical

1-888-973-0727

Applied Behavior Analysis (ABA) requests

1-617-246-4281

Commercial HMO/POS and PPO Plans

For:	Fax:
Medical pre-authorizations and referrals: Inpatient authorizations Outpatient authorizations Medical Policy Referrals Updates to existing cases (you can use the Updates to Existing Authorizations form)	1-888-282-0780
Emergent inpatient notification	1-866-577-9678
If we request additional clinical and concurrent reviews	1-888-282-1321
Musculoskeletal clinical	1-888-641-1375
Outpatient Physical, Occupational and Speech Therapy authorizations	1-866-577-9901
IVF authorizations and referrals	1-800-836-1112
Skilled nursing facility, rehabilitation hospital, long term acute care, inpatient hospice and respite	1-888-641-5330
Medical oral surgery requests	1-888-282-1315

Federal Employee Program Plans

For:	Fax:
Federal Employee Plan authorizations	1-888-282-1315
Federal Employee Plan: Additional requested clinical information	1-866-577-9682

Medicare Plans

For:	Fax:
Medex^®': Authorizations and referrals	1-617-246-4210
Medicare Advantage: Authorizations and referrals	1-800-447-2994
Medicare Advantage: Additional requested clinical information	1-866-577-9682
Medicare Advantage: Skilled nursing facility, rehabilitation hospital, and long term acute care facility	1-800-205-8885

Blue Cross Blue Shield of Massachusetts Employees

For:	Fax:
BCBSMA employees: medical authorizations and referrals	1-617-246-4299
BCBSMA employees: behavioral health/substance use authorizations and referrals	1-888-608-3693

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