Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member, please register here.

If you are a Medicare Advantage or Medicare Supplement member, please register here.

PAP241

Prior Authorization Requirements


Provider Administrative Policy

Section
General Billing
Policy Date
February 2008
Status/Date
Revised/March 2015
Provider Type(s)
All Providers  

Disclaimer

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


Policy

Prior Authorization Requirements

Connected Care referrals
For connected Care members, primary care physicians (PCPs) are required to submit a referral when referring a patient to an in-network contracting provider. If the services are not available in-network, all referrals to an out-of-network, non-contracting provider require prior authorization by Blue Cross of Idaho. All out-of-network referral requests must be submitted online, via fax or mail with supporting clinical documentation or medical records to: 

Fax: 208-331-7344
   
Mail: Blue Cross of Idaho
Attn: Medical Review Department                                                     
PO Box 7408
Boise, ID 83707
Confidential Request
 

For Behavioral Health prior authorizations refer to PAP902.

Please see below for more information regarding online authorization submission.

Service Requests

Prior authorization
Prior authorization is the process of determining the medical necessity of elective inpatient admissions and selected outpatient procedures, surgeries or drugs categorized as one of the following:

  • High utilization
  • High cost
  • Potentially cosmetic
  • Investigational or experimental in nature

We perform prior authorization on a prospective basis to gather the clinical information necessary to determine if the services requested are eligible for coverage under the member's benefit plan. the process involves working with providers to obtain the necessary medical records and treatment plan to determine he medical necessity for the planned services.

Please submit elective prior authorization requests at least 10 days prior to the scheduled date of service. The ordering physician should submit the prior authorization request online, via fax or mail with the following information to Blue Cross of Idaho.

  • All medical records documenting the clinical indications and/or medical necessity
  • Mark "Urgent Request" if the determination is urgent and please include the reason for the urgency. We will honor urgent requests if the documentation supports the definition of urgent care as attested to by the ordering provider.

Definition of urgent care
Urgent care is any request for medical care or treatment which the time periods for making non-urgent care determinations could result in the following circumstances:

  • Could seriously jeopardize the life or health of the member or the ability to regain maximum function, based on a prudent layperson's judgment, or
  • In the opinion of a practitioner with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

Certain Blue Cross of Idaho groups may not require prior authorization for listed services on this policy. Please verify prior authorization or medical necessity review requirements on the eligibility section at bcidaho.com or contact our Customer Service Department.

Prior authorizations when Blue Cross of Idaho is secondary
Prior authorization is not required when Blue Cross of Idaho is the provider of secondary coverage. If the primary carrier denies the charges, Blue Cross of Idaho may require a post-service review if there is no authorization on file. All services, whether primary or secondary, may be subject to medical necessity review.

To get a prior authorization form (including a list of services requiring prior authorization), or log in to the secure provider portal at bcidaho.com:

  • Select Authorizations/Notifications
  • Select Click to Access Authorization/Notifications under Authorization/Notifications

If you need training or assistance with the provider portal for submission of online authorizations, please contact your external provider relations representative. (See PAP100).

Fax: 208-331-7344
 
Mail: Blue Cross of Idaho
Attn:  Medical Review Department
PO Box 7408
Boise, ID 83707
Confidential Request

Pharmacy Requests

Pharmacy prior authorization
A list of medications requiring prior authorization is available on the Blue Cross of Idaho website at bcidaho.com.

  • Select Providers
  • Log in and select Prescription Drugs
  • Select Drugs Requiring Prior Authorization

Please submit elective prior authorization requests at least 10 days prior to the scheduled date of service. The ordering physician should submit the prior authorization request online, via fax or mail with the following information to Blue Cross of Idaho:

  • All medical records documenting clinical indications and/or medical necessity.
  • Mark "Urgent Request" if the determination is urgent and include the reason for the urgency. We will honor urgent requests if the documentation supports the definition of urgent care as attested to by the ordering provider.

Definition of urgent care
Urgent care is any request for medical care or treatment which the time periods for making nonurgent care determinations could result in the following circumstances:

  • Could seriously jeopardize the life or health of the member or the ability to regain maximum function, based on a prudent layperson's judgment, or
  • In the opinion of a practitioner with knowledge or the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

Select this link to receive a pharmacy prior authorization form, or log in to the secure provider portal at bcidaho.com.

  • Select Authorizations/Notifications
  • Select Authorizations/Notifications again

Or:

Fax: 208-387-6969
 
Mail: Blue Cross of Idaho
Attn:  Pharmacy Management Department       
PO Box 7408
Boise, ID 83707
Confidential Prior Authorization Request

Blue Cross of Idaho will notify the requestor with the prior authorization determination within 10 business days of receiving the completed non-urgent request, or 72 hours for urgent requests.

A complete authorization request with supportive clinical and diagnostic medical records will help us expedite the review process.

For emergency services, please notify Blue Cross of Idaho within 24 hours about services that typically require prior authorization.

AIM Specialty Health

For services authorized through AIM Specialty Health (AIM), please refer to the following PAPs:

  • PAP219 - AIM Specialty Health Advanced Imaging Prior Authorization
  • PAP285 - AIM Specialty Health Sleep Testing and Therapy

Pre-Service Provider Appeal

Contracting providers have one level of pre-service appeal. Refer to PAP236 for the provider inquiry and appeal process.

Advance Beneficiary Notice (ABN)

Contracting providers can collect the entire amount for any services that Blue Cross of Idaho deems "not medically necessary," only if they attach a "GA" Modifier to the claim indicating that they have an Advanced Beneficiary Notice (ABN) signed by the member stating that the  member has agreed to pay for the services even if not medically necessary.

On your remit, charges will show as a contractual adjustment, however, if the member has signed the ABN, you can bill the member for those services. Blue Cross of Idaho considers the ABN and the subsequent bill a matter between the member and the provider.

The ABN should include the following:

  • Member name
  • Member ID number including alpha characters
  • Provider name and address
  • Date of service
  • Procedure codes with descriptions
  • Reason why services may not be covered
  • Estimated charges
  • Statement that the member agrees to make payments to you
  • Date and signature from the member

Refer to PAP248 for an ABN example.

Refer to PAP100 for Medical Management contact numbers.

Refer to PAP279 for Clinical Criteria and instructions on how to obtain a copy of the clinical criteria.


Policy History

Date Action Reason
March 2015 Revised Added links to AIM PAPs and attestation for urgent requests
January 2015 Revised Removed all reference to a 'reconsideration' process and pointed all providers to PAP236
June 2014 Revised Added Definition of Urgent Care, Added revised provider reconsideration language
October 2013 Revised Added Refernce to PAP279 for Clinical Criteria
August 2012 Revised Removed hysterectomy and lap chole PA forms.
June 2012 Revised Updated online instructions
April 2010 Revised Group disclaimer added, form updated
October 2009 Revised Updated form and formatting
March 2009 Revised Phone number format updated
November 2008 Revised Advanced imaging updated to AIM
May 2008 Revised Updated form

Search for Policies

Policy Feedback