Blue Cross Blue Shield of Vermont (BCBS VT) has a prior authorization process that requires approval for certain medical treatments and services. This process is in place to ensure that the treatment is medically necessary and that the patient will benefit from it.
To initiate the prior authorization process, patients or providers can submit a request to BCBS VT. The request must include the patient's medical history, diagnosis, and treatment plan.
BCBS VT will review the request and make a decision within a specific timeframe, which is usually 24-72 hours. This timeframe may vary depending on the complexity of the case.
If the request is approved, the patient or provider will receive notification and the treatment can proceed as planned.
Understanding Prior Authorization
Prior authorization is a process used by Blue Cross Blue Shield Vermont (BCBS VT) to ensure that certain medications and treatments are medically necessary before covering them.
BCBS VT uses a list of approved medications to determine which ones require prior authorization. This list is updated regularly to reflect changes in medical research and treatment guidelines.
If a medication or treatment requires prior authorization, your doctor will need to submit a request to BCBS VT, which will then review the request to determine if it's medically necessary.
Clarifications
If you're a member of ABNE or NEHP, you should know that requirements only apply when you have a primary care provider (PCP) located in Vermont. This is an important distinction.
For members with a Vermont PCP, your Home Plan may manage mental health and pharmacy/mail order prescription drugs requirements and reviews.
However, if you're a Federal Employee Program (FEP) member, you have separate prior approval or referral authorization requirements. You'll need to check a separate list for details.
Here are the specifics:
- ABNE and NEHP members with Vermont PCPs: Home Plan manages mental health and pharmacy/mail order prescription drugs requirements and reviews.
- FEP members: separate prior approval or referral authorization requirements apply.
Listing of Items
Understanding Prior Authorization can be a complex process, but breaking it down into smaller parts can make it more manageable.
Cosmetic and Reconstructive Services require prior authorization, and you can find more information in the medical policy for Cosmetic and Reconstructive Procedures.
To initiate the prior authorization process, you'll need to use the Prior Authorization Portal through the Provider Resource Center or submit a State of Vermont Uniform Medical Prior Authorization Form.
Cosmetic and Reconstructive Services have specific requirements, including CPT/HCPCS Code and approval from Blue Cross VT, BEW Local 300, and the State of Vermont.
The following services require prior authorization:
- Cosmetic and Reconstructive Services
- Surgery
- Ambulance and Medical Transport Services
- Monitored Anesthesia Care (MAC)
- Applied Behavioral Analysis (ABA)
- Surgery
- External Insulin Pumps
- Occupational Therapy, Physical Therapy Medicine, and Speech Language Pathology/Therapy Services (for additional visits beyond the defined benefit limit)
- Autologous Chondrocyte Transplantation
Here's a list of services that require prior authorization:
- Cosmetic and Reconstructive Services
- Surgery
- Ambulance and Medical Transport Services
- Monitored Anesthesia Care (MAC)
- Applied Behavioral Analysis (ABA)
- Surgery
- External Insulin Pumps
- Occupational Therapy, Physical Therapy Medicine, and Speech Language Pathology/Therapy Services (for additional visits beyond the defined benefit limit)
- Autologous Chondrocyte Transplantation
Frequently Asked Questions
What is the phone number for BCBS of Vermont prior authorization?
To request prior authorization, call Blue Cross Blue Shield of Vermont at (800) 922-8778. Have the member's name, certificate number, and clinical details ready.
How do I get a prior authorization from insurance?
Contact your insurance company and provide required information to start the Prior Authorization process. Confirm with your healthcare provider if they have the necessary information and are willing to submit the request.
Does Blue Cross Federal require prior authorization?
Prior authorization may be required for certain services or treatments, depending on the type of care needed. Review our medical necessity guidelines to see if pre-approval is necessary for your benefit.
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