Prior Authorization Request - Blue Cross of Idaho
Prior Authorization Request - Blue Cross of Idaho
Prior Authorization Request - Blue Cross of Idaho
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<strong>Prior</strong> <strong>Authorization</strong> <strong>Request</strong><br />
Commercial Products Only<br />
(Please do not use for Medicare Advantage)<br />
• Submission <strong>of</strong> this information by fax or phone does not constitute authorization <strong>of</strong> services. <strong>Blue</strong> <strong>Cross</strong> <strong>of</strong> <strong>Idaho</strong>’s Medical Management<br />
department will notify you <strong>of</strong> their decision by secure email, mail, phone or fax. <strong>Authorization</strong> period may not exceed three months without<br />
review <strong>of</strong> medical records. If medical necessity justifies special handling, please include an explanation.<br />
• Please fax this completed form, along with the medical records documenting the clinical indications or medical necessity to the appropriate<br />
fax number listed below. For questions regarding this form, please call (208) 331-7535 or (800) 743-1871.<br />
• Please submit all elective prior authorization requests at least 10 days prior to the scheduled date <strong>of</strong> service.<br />
• If the request is URGENT please check here: q Reason for Urgent: ______________________________________________________<br />
q Federal Employee Program: Fax (208) 286-3551<br />
q Inpatient/Home Health/Hospice : Fax (208) 331-7326<br />
q Procedures/Services: Fax (208) 331-7344<br />
<strong>Request</strong>ing Provider:<br />
Date:<br />
Contact Person: Phone: Fax:<br />
Patient Name:<br />
Date <strong>of</strong> Birth:<br />
Enrollee ID:<br />
ICD-9-CM DX Code(s):<br />
Services <strong>Request</strong>s: Elective procedures and services subject to medical necessity review are listed on the back <strong>of</strong> this form.<br />
Facility: Phone: q Inpatient q Observation q Outpatient<br />
HCPCS/CPT® Procedure Code(s)<br />
Description<br />
Date <strong>of</strong><br />
Service<br />
Durable Medical Equipment (DME) <strong>Request</strong>s:<br />
HCPCS Code(s) Description Length <strong>of</strong> Need Rental or Purchase Price<br />
Referral for Non-Contracting Pr<strong>of</strong>essional Services (managed care only): Referral due to gap in network.<br />
Refer to Provider: Phone: Specialty:<br />
Appt. date:<br />
q One consult with follow up visit<br />
q Assume management for this<br />
specific condition<br />
Additional Information: If medical necessity justifies special handling, please include explanation.<br />
q Q 3 mos q Q 6mos<br />
Number <strong>of</strong> visits:<br />
Form No. 12-104 (08-07)
Services Requiring <strong>Prior</strong> <strong>Authorization</strong><br />
<strong>Prior</strong> authorization for the following may not be required for specific employer contracts but will be reviewed upon request.<br />
Procedures:<br />
• Arthroscopic surgery<br />
• Dental surgery related to an accident<br />
• Eyelid surgery<br />
• Gallbladder surgery<br />
• Gastric reflux surgery<br />
• Hysterectomy<br />
• Invasive treatment <strong>of</strong> lower extremity<br />
veins<br />
• Major joint replacement surgery<br />
• Nasal and sinus surgery<br />
• Orthognathic and TMJ surgery<br />
• Reconstructive and plastic surgery<br />
• Spinal surgery<br />
• Surgery for snoring or sleep problems<br />
• Surgical treatment <strong>of</strong> obesity<br />
• Transplants (organ, tissue, etc)<br />
• Experimental or investigational<br />
procedures*<br />
*Please refer to BCI Medical Policies on our Web<br />
site to search for our current policy regarding a<br />
specific procedure or diagnostic test. Any approval<br />
for investigational or experimental procedures will<br />
be done on a case-by-case basis upon review <strong>of</strong><br />
supportive literature and clinical information.<br />
State or federal mandates (e.g., FEP) may<br />
dictate that all FDA-approved devices may not be<br />
considered investigational and thus these devices<br />
may be assessed only on the basis <strong>of</strong> their medical<br />
necessity.<br />
Inpatient Admissions:<br />
• Acute inpatient hospital to include<br />
mental health/substance abuse (MH/SA)<br />
• Newborns requiring care beyond the<br />
normal newborn period<br />
• Rehabilitation and long-term care<br />
facility<br />
• Skilled nursing facility<br />
• Sub-acute and transitional care<br />
Note: Emergency admissions, please notify BCI<br />
within one business day following admission.<br />
Durable Medical Equipment:<br />
• CPAP/BIPAP<br />
• Home oxygen therapy<br />
• DME >$300 (including rent to<br />
purchase)<br />
• Covered orthotics and prosthetics >$300<br />
Services:<br />
• Diabetic self-management education<br />
• Genetic testing<br />
• Home health services<br />
• Home IV services<br />
• Hospice services<br />
• Hyperbaric oxygen therapy<br />
• Non-emergent ambulance transport<br />
Advanced Imaging:<br />
• MRI/MRA, CT and PET scans<br />
(Through NIA (800) 642-2798)<br />
• PET scans for all groups not participating<br />
in NIA<br />
Medications:<br />
Please refer to our Web site for a current<br />
listing <strong>of</strong> medications requiring prior<br />
authorization.<br />
Additional prior authorization<br />
requirements for managed care:<br />
• All services provided by non-contracting<br />
providers<br />
• Mental health/substance abuse<br />
(MH/SA)<br />
Northern <strong>Idaho</strong> and Eastern<br />
Washington – When the member’s PCP<br />
is located in Benewah, Bonner, Boundary,<br />
Kootenai and Shoshone counties in <strong>Idaho</strong><br />
and Spokane and Pend Oreille counties<br />
in Washington, the member must contact<br />
North <strong>Idaho</strong> Health Network at<br />
(208) 666-3212 or (800) 562-9608 to<br />
access MH/SA services.<br />
All other <strong>Idaho</strong> Locations – Members<br />
must access MH/SA services through<br />
Business Psychology Associates (BPA) at<br />
(888) 212-2932.<br />
Questions? Call <strong>Blue</strong> <strong>Cross</strong> <strong>of</strong> <strong>Idaho</strong> (208) 331-7535 or (800) 743-1871<br />
Updated August 2007<br />
Form No. 12-104 (08-07)