The services listed below may require precertification for your Blue Cross patients including those with Blue Advantage plans. To see if precertification is needed for a patient, check eligibility and benefits through ProviderAccess.
Submit All Preservice Reviews Electronically
Electronic preservice review is now available for all services requiring precertification. Submitting electronically instead of fax offers faster, often immediate approvals.
Getting Started
From Eligibility & Benefits, look for the green GO button to proceed with the electronic submission. The GO button appears whenever a precertification is required for the selected service type.
Additional Enhancements
From the Pre-Service Review Status section under the Action column, the following additional features are available:
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Upload additional supporting clinical documentation when a review is pended with a request for additional documentation to support medical necessity. |
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Initiate a continued stay request/request for continuation of services for a previously approved precertification by selecting the Edit (pencil) icon. |
Precertification requirements are subject to change at any time so it's important to check eligibility requirements for the specific date of service for the procedure or equipment.
Advanced Imaging
Blue Advantage Provider-Administered Drugs
Chiropractic
Durable Medical Equipment (DME)
FEP Prior Approval Drug List
Genetic Testing
Home Health
Home Infusion
Hospice
Provider-Administered Drugs
Radiation Therapy
Surgical Services
Therapy - Occupational, Physical, Speech
Pre-Service Review for Out-of-Area Members
Blue Cross and Blue Shield Plans give providers the ability to access out-of-area member’s Blue Plan provider portals to conduct electronic pre-service review.
To determine whether precertification is needed for a patient, always check eligibility and benefits through ProviderAccess.
Inpatient Hospital
Precertification is required for some inpatient surgical procedures that fall outside of the Concurrent Utilization Review Program (CURP) process. The admitting physician is responsible for initiating and obtaining the precertification prior to the patient being admitted to the hospital.
Predeterminations
Courtesy predetermination will be provided for the services below when performed in an outpatient setting. Precertification is required if performed in an inpatient setting.
FORMS & MANUALS