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Care Management

Commercial (PPO, Traditional and POS)

Go to Medicare Advantage

Prior Authorization List
Blue Cross of Idaho member contracts require certain services to be authorized before services are rendered. This list includes services which require prior authorization.

Medical Policies
The policies are used for the express purpose of assisting physicians and other healthcare providers in providing evidence based cost effective care. These policies may not apply to all lines of business such as the Federal Employee Program, Medicare Advantage True Blue, and certain self-insured groups.

CPT/HCPCS Codes Considered Investigational
This list includes codes always considered investigational by Commercial Medical Policy.

List of Cosmetic Codes
CPT and HCPCS codes that are considered by Blue Cross of Idaho to be cosmetic and ineligible for benefits are listed here. Blue Cross of Idaho considers the following codes to be cosmetic for commercial products (excluding Medicare).

Lumbar Spinal Surgery Pre-Authorization Guidelines (Laminectomies)
Outlines requirements for pre-authorization submissions regarding spinal surgeries, specifically for lumbar laminectomies and hemi-laminectomies.

Lumbar Spinal Surgery Pre-Authorization Guidelines (Lumbar Fusion)
Outlines requirements for pre-authorization submissions regarding spinal surgeries, specifically for lumbar fusions.

Cervical Spinal Surgery Pre-Authorization Guidelines (Cervical Fusion)
Outlines requirements for pre-authorization submissions regarding spinal surgeries, specifically for cervical fusions.

If you are looking for prescription drugs, IV therapies, nutritional formula, etc... that require prior authorization, please refer to the Pharmacy Management page.

Forms

Commerical Prior Authorization Request Form
Printable form used for prior authorization submissions

Medicare Advantage (includes TrueBlue® and SecureBluesm)

Medicare Advantage Prior Authorization List
This list is effective January 1, 2010. These codes will be the guideline to aid providers in determining whether a service will require prior authorization.

Medicare Advantage Drugs that Require Prior Authorization
Reference for drugs that need prior authorization for Medicare Advantage Plans

Medicare Advantage Self-Administered Drugs
Blue Cross of Idaho Medicare Advantage considers the drugs in the attached document to be self-administered and therefore not covered under Part B services. This is effective 01/01/2013.

Lumbar Spinal Surgery Pre-Authorization Guidelines (Laminectomies)
Outlines requirements for pre-authorization submissions regarding spinal surgeries, specifically for lumbar laminectomies and hemi-laminectomies.

Lumbar Spinal Surgery Pre-Authorization Guidelines (Lumbar Fusion)
Outlines requirements for pre-authorization submissions regarding spinal surgeries, specifically for lumbar fusions.

Cervical Spinal Surgery Pre-Authorization Guidelines (Cervical Fusion)
Outlines requirements for pre-authorization submissions regarding spinal surgeries, specifically for cervical fusions.

Forms

If you are requesting coverage for an out-of-network Behavioral Health provider, please refer to the Behavioral Health Additional Services Request form.

Medicare Advantage Prior Authorization Request Form
Printable form used for prior authorization submissions

Medicare Advantage Home Health Updates
Printable form used when requesting additional home health visits or recertification. return to top of page