Prior authorization

About prior authorization

Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) requires prior authorization (PA) for some covered admissions, continued stays, services, procedures, drugs and medical devices before they’re covered.

Prior authorization is a review and approval before a service happens to determine whether it’s medically necessary and appropriate. Prior authorization needs vary by the type of health plan the member has.

• Use commercial and Medicare plans prior authorization lookup tool

See coverage documents: Getting a prior authorization does not guarantee coverage. Whether or not authorization is required, coverage depends on the relevant medical policy or evidence-based coverage criteria. Each time a member seeks services, you also need to verify benefits and eligibility. All applicable terms and conditions of the member’s plan, including coverage exclusions, network requirements, deductibles, copayments and coinsurance apply with an authorization.

Prior authorization for medical plan benefits

Step 1: Determine whether prior authorization is needed

Acute hospital care

• Admission: Notify Blue Cross about all planned and unplanned admissions. Include medical records that support the need for inpatient care. Some hospital admissions require plan approval and will be reviewed for medical necessity. Note: Observation care (also known as 23-hour observation) does not require notification or approval.
• Continued stay: Notify Blue Cross when a member stays inpatient longer than planned or approved. Include medical records that support the need for continued stay.
• Discharge from hospital: Notify Blue Cross when a member is discharged from the acute level of care. Include the discharge summary with the date they were discharged and where they went.

Post-acute facility care

• Admission: Post-acute care includes acute rehabilitation, long term acute care, skilled nursing facility care, and residential treatment. All post-acute admissions require plan approval and will be reviewed for medical necessity. Submit a prior authorization request with medical records that support the need for the requested level of care.
• Continued stay: All continued stays in a post-acute facility require plan approval. Submit a prior authorization request with medical records that support the need for additional days at the requested level of care.
• Discharge from a post-acute facility: Notify Blue Cross when a member is discharged. Include the discharge instructions with the date they were discharged and where they went.

All other care

For other services, procedures, drugs and medical devices, prior authorization needs vary by the type of health plan the member has. These resources can help:

BlueCard members from other Blue Plans

Use the Blue Cross Blue Shield Plan’s Electronic Provider Access router tool to access other Blue Plan’s provider portals for prior authorization reviews for BlueCard members, including our Alternative Health Plan Portfolio members.

Enter the member’s three-character prefix to be routed to their Blue Plan’s EPA page. You can access the Blue Plan’s prior authorization information and any online pre-service review processes they offer. (This tool is also in Availity Essentials' Authorization tool.) See other states' info.

Federal Employee Program (FEP)

Use the applicable Service Benefit Plan brochure to determine whether authorization is required for a service or group of services. See “Section 3: How You Get Care.” See FEP brochures.

Step 2: Submit a request for prior authorization (if needed)

Request authorization online

The most efficient way to submit and manage requests for prior authorization is to log in at Availity.com/Essentials. Blue Cross participating providers are required to use the Availity Essentials portal to submit prior authorization requests, admission notifications and continued stay notifications.

Request PA on Availity Essentials

• Not using Availity Essentials yet? Any provider can register. You can submit prior authorization requests and check their status too. Register for Availity Essentials today.

Request authorization by fax

Use the most applicable fax form for the admission, service, procedure, drug or medical device being requested. Fax numbers and mailing addresses are on the forms.

• View and download forms