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 under age 65, please register here.

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

New Options for Affordable Health Insurance

PAP241

Prior Authorization Requirements


Provider Administrative Policy

Section
General Billing
Policy Date
February 2008
Status/Date
Revised/October 2013
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

Out-of-Network Referrals
For commercial managed care members, primary care physicians (PCP) are not 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. You must fax or mail all out-of-network referral requests and supportive 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.

Service Requests

Prior Authorization
Prior authorization is the process of determining the medical necessity of elective inpatient admissions and selected outpatient procedures, surgeries, services 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 medical necessity for the planned services.

Please submit all elective prior authorization requests at least 10 days prior to the scheduled date of service. If the service is Urgent, please note the reason for the urgent request so it can be prioritized and completed within 72 hours of the request. 

Select 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 of the Web site or contact customer service.

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 requires a post-service review if there is no authorization on file. All services, whether primary or secondary, may be subject to medical necessity review. 

Prior Authorization Form  (includes list of services requiring prior authorization)

Online:   

  • Go to:  bcidaho.com
  • Select Providers
  • Log on using your username and password
  • Select Authorizations/Notifications
  • Select Click to Access Authorization/Notifications under Authorization/Notifications 

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

Pharmacy Requests

Pharmacy Prior Authorization
A list of medications requiring prior authorization is available on the Blue Cross of Idaho Web site at
bcidaho.com.

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

The ordering physician needs to request the prior authorization (see link below) by faxing or mailing the following information to Blue Cross of Idaho:

  • Completed Prior Authorization Request form
  • All medical records documenting the clinical indications and/or medical necessity
  • Mark “Urgent Request” if the determination is urgent. Please understand that we only honor urgent requests if the documentation supports that the determination could seriously jeopardize a member’s life, health, ability to regain maximum functions or subjects the member to severe pain not manageable without treatment.

Pharmacy Prior Authorization Form

Online:

  • Go to:  bcidaho.com
  • Select Providers
  • Log on using your username and password
  • Select Authorizations/Notifications
  • Select Click to Access Authorizations/Notifications under Authorizations/Notifications  

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

Blue Cross 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 completed form submitted with supportive clinical and diagnostic medical records will help us expedite the review process. Additional forms are available on the Blue Cross of Idaho Web site at bcidaho.com.

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

Provider Reconsideration of Prior Authorization Denials
Blue Cross of Idaho offers providers two levels of reconsideration review of a denied prior authorization request. Blue Cross of Idaho may offer external review on a prospective review basis. Blue Cross of Idaho does not offer reconsiderations and external review for conditions, services or procedures excluded under the member contract.

Providers must initiate reconsideration requests within 60 days of the original authorization denial letter.

Initial Reconsideration - If a provider is dissatisfied with an authorization determination, he or she can request reconsideration by submitting a written or faxed request with additional supportive documentation to Blue Cross of Idaho's Medical Review Department. Blue Cross of Idaho will issue a reconsideration determination within 10 business days of receiving the reconsideration request.  For initial reconsideration requests for AIM Advanced Imaging prior authorization denials, please refer to PAP 251.

Subsequent Reconsideration - If a provider is not satisfied with the initial reconsideration determination, the provider may submit a second written or faxed reconsideration request with additional supportive documentation to Blue Cross of Idaho's Medical Review Department. Blue Cross of Idaho will issue a reconsideration determination within 10 business days of receiving the subsequent reconsideration request.

A provider cannot exercise appeal rights on behalf of the member without the member's express written authorization. Our determination of the provider's request for reconsideration does not affect the member's appeal rights under his or her policy.

Retrospective authorizations
Submit retrospective authorization requests along with supportive clinical documentation before, or at the time of, claim submission. We will determine medical necessity based on the information available at the time of claim review. If we deny the claim, the provider may dispute the claim decision with a formal request in writing. Refer to
PAP236 for specific instructions about 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
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