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Members of some group health plans may have terms of coverage or benefits that differ from the information presented here. The following information describes the general policies of Blue Cross and Blue Shield of Kansas (BCBSKS) and is provided for reference only. This information is NOT to be relied upon as prior-authorization or precertification for health care services and is NOT a guarantee of payment. To verify coverage or benefits or determine pre-certification or preauthorization requirements for a particular member, call 800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.
Pre-certification / Preauthorization information for out-of-area members
To view the out-of-area Blue Plan's general pre-certification/preauthorization information, enter the first three letters of the member's identification number on the Blue Cross Blue Shield ID card, and click "GO."
Alpha prefix:
If you experience difficulties or need additional information, please contact 800-676-BLUE.
Pre-certification required
- All in-patient medical stays (requires secure login with Availity) 800-782-4437
- All in-patient mental health stays 800-952-5906
- All home health and hospice services 800-782-4437
- Transplants with the exception of cornea and kidney 800-432-0272
Disclaimer: Some employer groups have some specific items that require prior authorization. Call for more information.
Predetermination/Prior-authorization required
Please complete and fax the BCBSKS predetermination or prior authorization form embedded within each policy below:
- ACA Prevention Copay Waiver Criteria – Individual Marketplace, Commercial
- Compounded Prescriptions
- Germline Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers
- Human Growth Hormone
- Immunoglobulin Therapy
- Site of Care Infusion Management
- Zolgensma
All other drugs may be prior authorized electronically by completing the prior authorization form through CoverMyMeds. If you need medical policies for these drugs, you will find a list below the CoverMyMeds form.
Many of our pharmacy medical policies are now being maintained through our pharmacy benefit manager, Prime Therapeutics.
To find pharmacy medical policies specific to a medication list, use the links below.
- BCBSKS BlueCare/EPO Prior Authorization (offsite link)
- BCBSKS ResultsRx Prior Authorization (offsite link)
- BCBSKS Select Prior Authorization (offsite link)
Policies may be temporarily housed here prior to being posted to the myprime.com website.
- GLP-1 (glucagon-like peptide-1) Agonists Prior Authorization with Quantity Limit
Check first: Be sure services that need approval are approved in advance
It's always wise to check your benefits so you know whether a service is covered and confirm that your doctor is in your plan's network. And, for some services, an approval for coverage is also needed. Getting approval in advance is called “prior authorization” or “PA.” If you don't have prior authorization for a service that needs one, the service may not be covered and you may be responsible for the entire cost of your care.
It's easy to find out if approval is needed
Generally, your doctor checks whether a service needs approval for coverage, but you can check online here too. You'll need:
- Your group number from your member ID card
- Date of your procedure
- Name of procedure or procedure code (get from your doctor)
Prior authorization lookup
When you look up your procedure, you'll find out if an authorization is needed and what to do next.
What is a 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
Without a prior authorization:
- Service may not be covered
- You may have to pay the entire cost of your care
Why is a prior authorization important?
- Prior authorization, sometimes called pre-certification, is how Blue Cross makes sure the treatment your doctor prescribes is medically necessary and helps ensure you are receiving proper care
- 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 health care services need prior authorization?
- Not all health care services need one. Prior authorization is required for various services, procedures, prescription drugs, and medical devices
- Please call Blue Cross customer service for any questions on prior authorizations
See if your service needs prior authorization
What services may need a prior authorization review?Below are examples of some procedures that 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
See the lists below for more details and Blue Cross customer service is also available to help you.
Prior authorization lists:You can also review a list of services that need prior authorization. You determine which list to use by the type of health plan you have. Please note that these lists change frequently and it's always best to call customer service to be sure.
- Commercial plans (PDF) (coverage you buy on your own or get through your employer)
- Minnesota Health Care Programs (Medicaid and MSHO)
- Medicare Advantage (PPO) plans (PDF)
- Medicare plans (Platinum Blue) (PDF)
- 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. Please 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, please call Blue Cross customer service and we can check on the status of the request.
What guidelines do you use?
Blue Cross and Blue Shield of Minnesota uses evidence-based guidelines from the World Health Organization to make prior authorization decisions. Registered doctors and nurses regularly review these guidelines.
About medical policy coverage
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 health care 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
About referrals
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.
How to appeal
Can I appeal a decision?
Yes, you have the right to appeal a prior authorization decision. Read more below about prior authorization appeals. To make an appeal, see complaints and appeals.
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 our 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 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 care 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.