What is prior authorization?
Prior authorization is you or your doctor's request to Blue Cross of Idaho, or delegated entity, for a medical necessity determination of a [proposed] medical or behavioral health service or procedure in advance of treatment. During this process, we may request and review medical records, test results and other information so that we understand what services are being performed, and are able to make an informed decision. We will determine if the requested service(s) are medically necessary and identified as covered services under the terms of your health insurance plan based on the information available. Typically, we complete this review within two business days. In some cases, we may require more information and will request additional records so that we can make a fully informed decision. This may result in a delay of our determination response.
We will notify you of our determination either in writing, or via telephone within two business days of receiving all necessary documentation. In addition, you can log into the member portal of our website to view the status of your authorization online. In the case of an emergency, you do not need prior authorization.
What services require prior authorization?
Out of nearly 10,000 defined healthcare billing codes, we limit prior authorization to a very small number of procedures, medications and services. We select these procedures based on comparative national data of services delivered in Idaho. The procedures we've identified have a significantly high incidence of being performed or prescribed when they may not meet medical necessity or other contractual criteria, or when an alternative service may be available. The medications requiring prior authorization are determined by the Blue Cross Pharmacy and Therapeutics Committee and the Chief Medical Officer. Our medical, behavioral health and pharmacy management staff follow specific clinical guidelines during the prior authorization process.
The following list of services requiring prior authorization may change. If you have questions, you can call us at the phone number on the back of your Blue Cross of Idaho member identification card. Also, ask your doctor if you need prior authorization for a specific treatment or service. We regularly provide physician offices with updates to the list of procedures requiring prior authorization.
Please note: The list of services requiring prior authorization, and specific requirements relating to such services, may vary for some employer groups. For specific information about the prior authorization requirements for your plan, please refer to your summary plan description, contract, or call our Customer Services Department at the phone number listed on the back of your Blue Cross of Idaho member identification card
Services requiring prior authorization
Surgical Services – Inpatient or Outpatient
- Organ and tissue transplants
- Nasal and sinus procedures
- Eyelid surgery
- Spinal surgery
- Plastic and reconstructive surgery
- Surgery for snoring or sleep problems
- Invasive treatment of lower extremity veins (including but not limited to varicose veins)
- Advanced imaging services – MRI, MRA, PET and CT scans
- Inpatient stays that originate from an outpatient service
- Home intravenous therapy
- Non-emergent ambulance
- Certain prescription drugs as listed on the prior authorization list
- Restorative dental services following accidental injury to sound natural teeth
- Hospice services
- Growth hormone therapy
- Genetic testing services
- Rental or purchase of durable medical equipment, prosthetic appliances or orthotic devices when the expected charges exceed $500 each
- Mental health and substance abuse services:
- Outpatient psychotherapy services after the 10th visit (does not include medication management services)
- Intensive outpatient program (IOP)
- Partial hospitalization program(PHP)
- Residential treatment program
- Psychological testing/neuropsychological evaluation testing
- Electroconvulsive therapy (ECT)
Why does Blue Cross of Idaho require prior authorization?
It's important for you to know your benefits and covered services. Covered services are medically necessary services, supplies and procedures specified as covered services in your contract, for which we provide benefits. It can be frustrating when a member or a doctor learns that a service is not covered under the terms and conditions of the member or provider contract after the service has been performed. We want to prevent that frustration. With prior authorization, Blue Cross of Idaho is able to:
- Confirm your specific treatment plan and medical necessity given your diagnosis
- Determine if services are eligible for coverage
- Ensure coordination of care
- Assure that your claims are processed accurately and timely
- Assist you in understanding your coverage, benefits and the contracting status of your doctor so that you are aware of your financial responsibility
With this information, you can talk with your doctor to make the best decision for your care.
Why is prior authorization important to you?
Prior authorization is just one of the ways we're working to address rising healthcare costs. Hospital and technology costs, and the increased use of healthcare services contribute to rising healthcare costs. As healthcare costs go up, health insurance premiums also go up to pay for the services provided.
As your healthcare company, we want you to receive the best care at the right time and place. We also want to ensure that you receive the right technology that addresses your particular clinical issue. We’re here to work with you, your doctor, and the facility so that you have the best possible health outcome.
What happens if I don't have prior authorization?
It depends on if your provider is contracting with Blue Cross of Idaho. Providers who contract with Blue Cross of Idaho must meet our prior authorization requirements. If you receive non-medically necessary services from a contracting provider without prior authorization and we deny benefits, you are not financially responsible for the cost of the services. If, on the other hand, you receive non-medically necessary services from a non-contracting provider, you will be held financially responsible for the cost of the services.
If you disagree with our determination that the service requiring prior authorization is not medically necessary, you can appeal the decision using the member appeal process as outlined in your summary plan description, policy or contract.
What prior authorization is not?
Prior Authorization is not a guarantee of payment. It is a pre-service determination of medical necessity based on information provided to Blue Cross of Idaho at the time the prior authorization request is made. Blue Cross of Idaho retains the right to review the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services.