Medical services that need prior authorization

What is prior authorization?

Prior authorization, sometimes called pre-certification, is how Blue Cross and Blue Shield of Minnesota makes sure the treatment your doctor prescribes is medically necessary and helps ensure you are getting proper care.

• We use established clinical guidelines to confirm medical necessity when your health plan requires prior authorization
• Services needing a prior authorization can vary depending on the type of health plan you have
• Whenever possible, get prior authorization before receiving treatment or check that your doctor has gotten approval. If you do not have approval before the service, you might have to pay for the cost

Which healthcare services need prior authorization?

• Prior authorization is required for various services, procedures, prescription drugs and medical devices. Not all healthcare services require prior authorization.
• Call the number on the back of your member ID card for questions on prior authorizations
• See if your service needs prior authorization

Below are examples of some procedures that may require prior authorization, depending on the benefits you have. It is not a complete list, and it changes frequently, so it is important to make sure your service is covered before getting care.

• Cardiology (ablation, stress test, advanced imaging, diagnostic and implantable device services)
• Medical oncology (chemo and supportive medical specialty medications treating active cancer diagnosis)
• Molecular lab (Breast Cancer (BRCA) gene testing, fetal chromosomal testing, molecular pathology)
• Musculoskeletal (spinal injections for pain management; knee, hip and shoulder surgery; fusions)
• Radiation therapy (surgical procedures such as mastectomy; radiation procedures such as 3D CRT and IMRT; surgical or radiation treatment of cancers)
• Radiology advance imaging (MRI, MRA, PET, CT, and Nuclear Studies)
• Sleep (sleep study, machine and supplies; apnea testing)
• Transplant services
• Some surgical procedures 
• Some behavioral health assessments and treatments
• Certain medicines including injectables and intravenous therapies
• Prosthetic supplies 
• Some medical equipment and devices including oxygen and wheelchairs
• Some services may require a prior authorization to continue receiving the service after a set number of visits, such as acupuncture and home health visits

Prior authorization lists:

You can also review a list of services that need prior authorization, determined by the type of health plan you have. These lists change frequently. Use the lookup tool or call the number on the back of your ID card to be sure.

• Commercial plans (coverage you buy on your own or get through your employer)
• Medicare Advantage (PPO) plans
• Platinum Blue^SM Medicare Cost plans
• Minnesota Health Care Programs – MHCP (Families and Children (PMAP), MNCare, MSC+)
• Minnesota Senior Health Options (MSHO)
• Federal employee program (Medical list is in service benefit plan brochure)

How do I get a prior authorization?

Sometimes your doctor’s office submits a prior authorization for you. Sometimes you need to request it. Call customer service at the number on the back of your member ID card for help.

You will receive a letter in the mail letting you know if your prior authorization was approved, denied or if more information is needed from your doctor. If you haven’t gotten your letter before your scheduled medical service, call the number on the back of your member ID card to check on the status of the request. 

What guidelines do you use?

Blue Cross uses evidence-based guidelines from the World Health Organization to make prior authorization decisions. Registered doctors and nurses regularly review these guidelines.

Why doesn’t my plan cover a treatment if my doctor recommends it?

Your health plan only covers health services and supplies that are medically necessary.

“Medically necessary” means that you need the healthcare service or supply to prevent, diagnose or treat an:

• Illness
• Injury
• Condition
• Disease or its symptoms

The service or supply must also meet accepted standards of medicine. If your condition causes harmful symptoms or side effects, your plan considers it medically necessary to treat them as well.

Your health plan may not cover some services and supplies that your doctor recommends.

To find out what your plan covers, check your health plan documents or call the number on the back of your member ID card.

Can I still get a treatment if my plan doesn’t cover it?

If your health plan does not cover a treatment, or if Blue Cross denies coverage, you can choose to receive it and pay for it on your own. Talk with your doctor to find out how much you will need to pay for any service your plan doesn’t cover. 

• See medical policy

Do I need a referral to see a specialist?

Whether you need a referral to see a specialist depends on your plan. Some plans allow you to see any doctor or specialist in your plan network without a referral. If you see a doctor or specialist that is not in your plan network, you may have to pay more. To find a doctor or specialist in your network, use the Find a Doctor tool. Sign in or choose your network name to be sure you’re searching the right network.

If you see a specialist without a referral, be sure to inform your primary care doctor. This information will help your doctor provide the best possible care.

What does a referral include?

A referral typically includes the office visit and any lab work your doctor may request, like x-rays or blood and urine tests. Other services, like shots or minor skin surgery, may require prior authorization.

Important: To find out what services require prior authorization, check your health plan documents, or call the number on the back of your member ID card.

Can I appeal a decision?

You have the right to appeal a prior authorization decision. Read more below about prior authorization appeals. To make an appeal, visit the complaints and appeals page.

How do I appeal a decision?

You, or a doctor or caregiver acting on your behalf may request an appeal.

You can start an appeal in one of two ways:

• Call the number on the back of your member ID card
• Mail a written appeal

What do I include in an appeal?

• Your name, address and member ID number
• The reasons you disagree with the decision
• Evidence that explains why we should approve your appeal, including medical records, letters from your doctors and other related information. Call your doctor if you need this information or have your doctor submit an appeal for you

If your doctor or caregiver is acting on your behalf, you must sign an authorization form that allows us to release your personal information to your representative. You can complete the authorization for disclosure of health information online.

When do I need to send my appeal?

• We must receive your appeal within 180 days from the time you receive a denial letter from us. If we deny a prior authorization, we'll send you and your doctor a denial letter
• In most cases, Blue Cross will complete appeal decisions with 15 days. All appeal decisions will be made within 30 days

What if my request is urgent?

If you need to expedite your appeal, call the number on the back of your member ID card. If your request qualifies, we will make a decision and notify you and your doctor within 72 hours after we receive your request.

Typically, a situation is urgent if your health is in serious jeopardy or you will be in severe pain that can’t be controlled while you wait for a decision.

If your request qualifies as urgent, you may also request an external appeal through an Independent Review Organization. For more information on your appeal rights, see your health plan documents or call the number on the back of your member ID card.

If you would like to start the appeal process, see complaints and appeals instructions.

How do I get a copy of my records?

To request a free copy of all the documents we use to decide your appeal, call the number on the back of your member ID card. You can also request a list of the diagnosis and treatment codes we use.