Blue Cross Community Prior Authorization Form Requirements and Reviews

To navigate the Blue Cross Community prior authorization form, you'll need to meet their specific requirements.

The form typically needs to be completed by the treating physician or other authorized healthcare provider.

Blue Cross Community may request additional documentation to support the request, which can include medical records, test results, or other relevant information.

This documentation helps ensure that the requested treatment is medically necessary and aligns with Blue Cross Community's coverage policies.

The review process usually takes 2-5 business days, but this timeframe may vary depending on the complexity of the request and the amount of documentation required.

In some cases, Blue Cross Community may request a peer-to-peer review, where a specialist reviews the case to ensure it meets their coverage criteria.

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Prior authorization may be required for certain treatments or services, and the need for prior review and authorization depends on your health insurance plan.

For Blue Cross NC members, you can check your Benefit Booklet in your Blue Connect℠ member portal for specific information about your insurance plan.

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If you're a Michigan provider, you should attach the completed assessment form to the request in the e-referral system, unless you're a non-Michigan provider, in which case you should fax the completed form using the fax numbers on the form.

Providers with access to Availity Essentials should attach the completed form to the request in the e-referral system, but those without access should fax the completed form instead.

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Prior review is a crucial step in the prior authorization process. It's a requirement for certain prescription medications, medical procedures, or healthcare services to be covered by your plan.

Blue Cross and Blue Shield of North Carolina, for example, requires prior review before your plan will help cover the cost of these services. This is also known as prior approval or prospective review.

You may have heard other names for prior review, such as prior authorization, certification, or precertification. Here are some examples:

In emergency situations, prior review isn't required. However, you should notify Blue Cross NC of an urgent or emergency admission by the second business day after the admission.

Prior authorization is required for certain services, treatments, and prescription drugs. This process ensures that your insurance provider reviews and approves the services before they're provided.

The prior review process typically involves several steps, including your healthcare provider submitting a prior authorization to your insurance company. Your insurance company will review the prior authorization and decide if it should be approved or denied.

Approved prior reviews are sent back to your provider, and you'll be notified if it's approved. Denied prior reviews are sent back to your provider with a reason for denial and information about how to submit an appeal to the insurance company.

You must get a prior review approved before receiving the services, treatments, or prescription drugs.

Some services always require prior authorization, such as elective services provided by or arranged at nonparticipating facilities.

Here are some examples of services that may require prior review:

In an emergency, prior review isn't required, but you should notify your insurance company as soon as possible.

If you're planning a medical procedure, it's essential to know what's covered by Blue Cross NC. Inpatient admissions, for example, are generally covered, but maternity stays longer than 48 hours after a vaginal delivery or 96 hours after a C-section may not be.

Inpatient admissions are usually covered, except for maternity admissions, elective, planned in advance, or not related to an emergency. This means you should have a valid medical reason for the admission.

Some medical procedures require prior review, such as private duty nursing, skilled nursing facility, acute rehabilitation admissions, home health care, and durable medical equipment. This ensures that the treatment is medically necessary and not elective.

Here are some medical procedures that require prior review or may not be covered: