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Secure Blue PPO Prior Authorizations

Provider Administrative Policy

Provider Prior Authorizations
Policy Date
May 2008
Revised/June 2014


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Secure Blue PPO Prior Authorizations

Contracting providers are responsible for obtaining the prior authorization on behalf of the member for the services shown below. Before rendering services, submit prior authorization requests via the  Blue Cross of Idaho Web site at, fax, or mail to the Medicare Advantage care coordination team. For purposes of benefit payment, we reserve the right to review all directed care requests and approve, disapprove or modify these requests. The fact that a physician performs or recommends services, supplies or equipment accommodations does not conclusively constitute or establish them as medically necessary or as a covered benefit.

Confirmation of a provider's contracting status is available on Blue Cross of Idaho’s Web site at or by calling Blue Cross of Idaho's Customer Service (see MA PAP102).

Medicare Advantage Prior Authorization Form 

The following services require prior authorization from a contracting provider and is suggested from a non-contracting provider:


Inpatient admissions - Prior authorization or inpatient notification is required for all procedures listed on the CMS Inpatient Only List. If the inpatient procedure (such as a joint replacement) requires a separate authorization, both the procedure and the inpatient procedure (such as a joint replacement) requires a separate authorization, both the procedure and the inpatient stay will require prior authorization. If the admission date is known at the time of the procedure authorization, both authorizations will be completed at the same time. If the admission date is known, the facility will be required to contact Blue Cross of Idaho before or at the time of inpatient admission.


For all other procedures, facilities must notify Blue Cross of Idaho of the inpatient admission at the point in time it is ordered and clinically indicated AFTER the standard post op recovery period. If a facility attempts to prior authorization an inpatient admission for a procedure that is not in the CMS inpatient only list, Blue Cross of Idaho may tell the provider a prior authorization of the surgical procedure is not required but an inpatient notification is. Following a surgery, if the patient is not clinically stable and ready for discharge, it is only then that the doctor can make the decision to admit the patient and it is at that point in time the facility must notify Blue Cross of Idaho of the inpatient admission.


Part B Drugs Requiring Prior Authorization

Self-Administered Drugs

  • Blue Cross of Idaho Medicare Advantage plans must comply with the CMS requirements for self-administered drugs.  Effective January 1, 2009, we consider self-administered drugs non-covered Part B services. Providers may need to re-evaluate the use of these medications for their Medicare Advantage patients.  A complete list of these medications may be found at the following link:SAD Drugs

Durable Medical Equipment (DME)

  • DME greater than $500 (including rental to purchase)
  • Orthotics and prosthetics greater than $500


Category III Codes

  • Unless specifically addressed as a covered service under either CMS National Coverage Determination or Local Coverage Determination, Blue Cross of Idaho Medicare Advantage will consider these codes as investigational and therefore, non-covered.
Diagnostic Studies
  • Advanced imaging (CT scans, MRI/ MRA, PET scans, nuclear cardiology, functional brain MRI and T codes including virtual colonoscopy, see MA PAP302 )

Clinical Trials

Prior Authorization Submission Requirements:

Elective Procedures
Elective procedures are subject to medical review, as previously listed, require medical records and may take up to 14 calendar days to process. Please submit requests for planned surgical procedures 14 calendar days prior to the procedure to allow time for review and coordination of services. If medical necessity justifies special handling, please include an explanation.

Retrospective Authorization
Retrospective authorization will not be accepted. If a contracting provider does not obtain prior authorization before rendering services, the provider should submit a claim for processing. Upon denial, the provider may dispute the claim decision by formally requesting reconsideration. A reconsideration request must include supporting documentation.

Prior Authorization Request
Complete prior authorization requests include:

  • Member name, ID number and date of birth
  • Requesting provider name and number
  • Name and specialty of provider to whom the patient is referred
  • Date of appointment
  • Requested services (scope of services)
  • Name and phone number of staff member completing the form
  • Diagnosis (ICD-9-CM)
  • Procedure code (CPT®)
  • Remarks specific to this request

If a member’s condition is the result of an accident or work-related injury, please complete the appropriate area of the form with as much information as possible. The provider`s office is responsible for claim submission to labor and industry and other primary carriers directly.

Submit prior authorization request and all pertinent medical documentation to the Medicare Advantage care coordination team via:

  • Web site:
  • Fax: 208-395-8204
  • Mail:Medicare Advantage Care Coordination Team
    P.O. Box 8406
    Boise, ID  83707

To request changes to an existing authorization, please contact the Medicare Advantage care coordination team (see MA PAP102 ).

Before providing any services to Secure Blue PPO members, be certain to have an approved authorization issued by the Medicare Advantage care coordination team. Services rendered without prior authorization from a contracting provider may result in nonpayment of claims. Visit the Blue Cross of Idaho Web site at to check prior authorization status.  Phone confirmation may be available from Blue Cross of Idaho Customer Service before receiving written authorization.

Prior authorizations are limited to a specific period of time, number of visits or scope of services.

No prior authorization is required for emergency services in any setting.

Prior authorization requirements do not apply to providers who are not contracted with the plan; however, advance determination of services listed above is recommended.

Advance Determination Request

Policy History

Date Action Reason
June 2014 Revised Removed services no longer requiring prior auth.
October 2013 Revised Updated SAD Drug List
February 2013 Revised Language clarification OP MHSA, link added to form, Language added to Inpatient Admissions section
October 2009 Revised Vision language removed
July 2009 Revised Formatting, link to MA PAP304 and additions to prior authorization list
March 2009 Revised Removed arthroscopies and added category III codes and self administered drugs
November 2008 Revised Advanced imaging language added
May 2008 Revised Prior authorization additions

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