Prior Authorization Request - Blue Cross of Idaho

Prior Authorization Request
Commercial Products Only
(Please do not use for Medicare Advantage)
• Submission of this information by fax or phone does not constitute authorization of services. Blue Cross of Idaho’s Medical Management
department will notify you of their decision by secure email, mail, phone or fax. Authorization period may not exceed three months without
review of medical records. If medical necessity justifies special handling, please include an explanation.
• Please fax this completed form, along with the medical records documenting the clinical indications or medical necessity to the appropriate
fax number listed below. For questions regarding this form, please call (208) 331-7535 or (800) 743-1871.
• Please submit all elective prior authorization requests at least 10 days prior to the scheduled date of service.
• If the request is URGENT please check here: q Reason for Urgent: ______________________________________________________
q Federal Employee Program: Fax (208) 286-3551
q Inpatient/Home Health/Hospice : Fax (208) 331-7326
q Procedures/Services: Fax (208) 331-7344
Requesting Provider:
Date:
Contact Person: Phone: Fax:
Patient Name:
Date of Birth:
Enrollee ID:
ICD-9-CM DX Code(s):
Services Requests: Elective procedures and services subject to medical necessity review are listed on the back of this form.
Facility: Phone: q Inpatient q Observation q Outpatient
HCPCS/CPT® Procedure Code(s)
Description
Date of
Service
Durable Medical Equipment (DME) Requests:
HCPCS Code(s) Description Length of Need Rental or Purchase Price
Referral for Non-Contracting Professional Services (managed care only): Referral due to gap in network.
Refer to Provider: Phone: Specialty:
Appt. date:
q One consult with follow up visit
q Assume management for this
specific condition
Additional Information: If medical necessity justifies special handling, please include explanation.
q Q 3 mos q Q 6mos
Number of visits:
Form No. 12-104 (08-07)

Services Requiring Prior Authorization
Prior authorization for the following may not be required for specific employer contracts but will be reviewed upon request.
Procedures:
• Arthroscopic surgery
• Dental surgery related to an accident
• Eyelid surgery
• Gallbladder surgery
• Gastric reflux surgery
• Hysterectomy
• Invasive treatment of lower extremity
veins
• Major joint replacement surgery
• Nasal and sinus surgery
• Orthognathic and TMJ surgery
• Reconstructive and plastic surgery
• Spinal surgery
• Surgery for snoring or sleep problems
• Surgical treatment of obesity
• Transplants (organ, tissue, etc)
• Experimental or investigational
procedures*
*Please refer to BCI Medical Policies on our Web
site to search for our current policy regarding a
specific procedure or diagnostic test. Any approval
for investigational or experimental procedures will
be done on a case-by-case basis upon review of
supportive literature and clinical information.
State or federal mandates (e.g., FEP) may
dictate that all FDA-approved devices may not be
considered investigational and thus these devices
may be assessed only on the basis of their medical
necessity.
Inpatient Admissions:
• Acute inpatient hospital to include
mental health/substance abuse (MH/SA)
• Newborns requiring care beyond the
normal newborn period
• Rehabilitation and long-term care
facility
• Skilled nursing facility
• Sub-acute and transitional care
Note: Emergency admissions, please notify BCI
within one business day following admission.
Durable Medical Equipment:
• CPAP/BIPAP
• Home oxygen therapy
• DME >$300 (including rent to
purchase)
• Covered orthotics and prosthetics >$300
Services:
• Diabetic self-management education
• Genetic testing
• Home health services
• Home IV services
• Hospice services
• Hyperbaric oxygen therapy
• Non-emergent ambulance transport
Advanced Imaging:
• MRI/MRA, CT and PET scans
(Through NIA (800) 642-2798)
• PET scans for all groups not participating
in NIA
Medications:
Please refer to our Web site for a current
listing of medications requiring prior
authorization.
Additional prior authorization
requirements for managed care:
• All services provided by non-contracting
providers
• Mental health/substance abuse
(MH/SA)
Northern Idaho and Eastern
Washington – When the member’s PCP
is located in Benewah, Bonner, Boundary,
Kootenai and Shoshone counties in Idaho
and Spokane and Pend Oreille counties
in Washington, the member must contact
North Idaho Health Network at
(208) 666-3212 or (800) 562-9608 to
access MH/SA services.
All other Idaho Locations – Members
must access MH/SA services through
Business Psychology Associates (BPA) at
(888) 212-2932.
Questions? Call Blue Cross of Idaho (208) 331-7535 or (800) 743-1871
Updated August 2007
Form No. 12-104 (08-07)