Understanding Bcbs Prior Authorization Forms and Lists

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Posted Dec 19, 2024

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Let's break down what you need to know about Blue Cross Blue Shield (BCBS) prior authorization forms and lists. BCBS prior authorization forms are required for certain medical treatments and services, which can vary by plan and provider.

These forms are used to verify that a treatment is medically necessary and meets the plan's guidelines. BCBS has a list of approved treatments and services that don't require prior authorization, which can be found on their website or through their provider portal.

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Prior Authorization Forms

To obtain prior authorization forms, you can visit the Blue Shield of California plan members' website or the Blue Shield Promise members' website. Both websites have a list of medical services and procedures requiring medical necessity review and/or supplemental documentation before payment is made.

You can also find prior authorization forms on the Blue Cross Complete website, where you'll need to submit a request using one of the following forms: a medication prior authorization request form or an electronic prior authorization through your Electronic Health Record tool software.

If you need to request prior authorization for specific medical equipment, such as an Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO), you can find the corresponding prior authorization forms on the Blue Cross Complete website.

Prior Authorization Lists

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Prior authorization lists are a crucial part of the healthcare system, and understanding them can save you time and stress.

You can view the list of medical services and procedures requiring medical necessity review and/or supplemental documentation before payment is made. This list is specific to Blue Shield of California plan members and Blue Shield Promise members.

To access the list, simply click on the link provided for your plan type.

There are two types of prior authorization lists: one for Blue Shield of California plan members and another for Blue Shield Promise members.

Behavioral Health Fax Forms

Behavioral Health Fax Forms are a crucial part of the prior authorization process.

You may need to submit fax forms for various behavioral health services, including inpatient psychiatric care. Inpatient Psychiatric Care Authorization Request (PDF) and Inpatient Psychiatric Care (PDF) forms are available for this purpose.

Partial Hospitalization Programs (PHP) Authorization Request (PDF) is another important form for behavioral health services. This form is used to request authorization for PHP services.

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If you're seeking authorization for Residential Treatment for Behavioral Health, you'll need to submit the Residential Treatment for Behavioral Health Authorization Request Form (PDF).

Here are some behavioral health fax forms you may need to submit:

  • Behavioral Health Care Length of Stay Extension Authorization Request (PDF)
  • Intensive Outpatient Program (IOP) Authorization Request (PDF)
  • Rapid Response Services for Behavioral Health Authorization Request (PDF)
  • Electroconvulsive Therapy (ECT) (PDF)
  • Transcranial Magnetic Stimulation (TMS) (PDF)
  • Psychological and Neuropsychological Testing Authorization Request (PDF)

Health Benefits and Claims

If you use a provider outside of the network, you will need to complete and file a claim form for reimbursement.

You'll need to use the Health Benefits Claim Form for this process.

Overseas members should use the Overseas Medical Claim Form, as specified for their specific needs.

This form will help you get reimbursed for out-of-network medical expenses.

Exception Forms

If you need to apply for coverage of a non-covered drug, you'll need to complete a Formulary Exception Form. This form is used to apply for coverage of a non-covered drug if you've tried and failed the covered drug(s).

The Formulary Exception process allows you to apply for coverage of a non-covered drug if you've tried and failed the covered drug(s). You'll need to select the list of exceptions for your plan.

There are different types of exception forms, including the Contraceptive Exception Form, which allows you to apply for coverage or formulary tier exception for a contraceptive drug/product.

Recommended read: Bcbs Drug Formulary 2023

Authorized Representative Designation

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An Authorized Representative Designation form is used to select an individual or entity to act on your behalf during the disputed claims process.

This form is specifically designed for situations where you need someone to represent you in a claims process, such as when you're unable to act on your own behalf.

The form is typically used to designate a specific person or entity to handle your affairs, giving them the authority to make decisions and take actions on your behalf.

For example, you might use this form to designate a family member or trusted friend to act on your behalf if you're unable to do so yourself.

Formulary Exception Form

To apply for coverage of a non-covered drug, you'll need to fill out a Formulary Exception Form. This form allows members to apply for coverage of a non-covered drug if they've tried and failed the covered drug(s).

The Formulary Exception process is a crucial step in getting the medication you need. Select the list of exceptions for your plan to ensure you're filling out the correct form.

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You'll need to complete and file a request form for all formulary tier exceptions. This form is a necessary step in the process.

The Formulary Exception Form is a straightforward process, but it's essential to follow the correct steps. By filling out this form, you can get the coverage you need for your non-covered drug.

Durable Medical Equipment Fax Forms

If you need to request prior authorization for certain durable medical equipment, you'll need to complete and fax the relevant forms.

For example, if you're requesting authorization for an Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO), you'll need to use the Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO) PA Request Form (PDF).

Similarly, if you're requesting authorization for a Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep Apnea, you'll need to use the Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep Apnea PA Request Form (PDF).

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Here are some of the durable medical equipment fax forms you may need to use:

EquipmentPA Request Form
Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO)Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO) PA Request Form (PDF)
Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep ApneaBi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep Apnea PA Request Form (PDF)
Continuous Positive Airway Pressure (CPAP) Rental or PurchaseContinuous Positive Airway Pressure (CPAP) Rental or Purchase Prior Authorization (PA) Request Form (PDF)
Knee OrthosisKnee Orthosis PA Request Form (PDF)
Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO)Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO) PA Request Form (PDF)
Negative Pressure Wound Therapy (NPWT) Pump RentalNegative Pressure Wound Therapy (NPWT) Pump Rental PA Request Form (PDF)
Non-invasive Home VentilatorNon-invasive Home Ventilator PA Request Form (PDF)
OxygenOxygen PA Request Form (PDF)
Standard WheelchairStandard Wheelchair PA Request Form (PDF)

Make sure to review the specific requirements for each form and follow the instructions carefully to ensure your request is processed efficiently.

Medicare Plans

Blue Shield of California offers several Medicare Advantage plans, including Blue Shield TotalDual (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP). These plans require specific templates and non-disclosure attachments for notifying plan members regarding authorization determinations.

The templates include a carveout notice and a detailed explanation of non-coverage, both of which must be accompanied by non-disclosure attachments in the member's preferred language.

To access these templates, you can download them from the Blue Shield of California website.

If you're looking for experience health Medicare Advantage forms, you can find them online, including a durable medical equipment (DME) repair or replacement prior authorization request form.

For Medicare Advantage appeals, Blue Shield offers a range of forms, including a provider dispute resolution procedure, provider reconsideration form, and provider appeal form.

You can also find information on Medicare Advantage authorizations, such as the administered part-B specialty drug list and care management contact information.

Vanessa Schmidt

Vanessa Schmidt

Lead Writer

Vanessa Schmidt is a seasoned writer with a passion for crafting informative and engaging content. With a keen eye for detail and a knack for research, she has established herself as a trusted voice in the world of personal finance. Her expertise has led to the creation of articles on a wide range of topics, including Wells Fargo credit card information, where she provides readers with valuable insights and practical advice.

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