Many services require review before they are provided. Whenever possible, submit a review request before providing the service. This helps us pay claims faster with no unexpected cost to you or the member after the services are provided.
Sometimes a service requires prior authorization. If you don't get a prior authorization, it could result in a payment penalty for you or the member. Please note that you can't submit a prior authorization request by phone.
When a service requires pre-service review, there isn't a penalty, but we'll hold the claim and ask for medical records.
1. Find out if a code needs review
To see if we require a prior authorization or a pre-service review, use our code check tool.
Or, you can find member-specific information by logging in to our prior auth tool.
Note: The tool does not work with home health, durable medical equipment (DME), or non-specific/unlisted codes.
2. Submit a prior auth request
Submit a request using our prior auth tool. (You'll need the member ID.) It takes into account the member's eligibility, their coordination of benefits, and whether or not their plan requires authorization for the requested services. You can attach records online and get an instant reference number.
You can also complete and fax our request form to 800-843-1114. Be sure to include the needed supporting documentation (see code list for details).
View our prior auth online tool guide for helpful tips.
3. Check prior auth review status
Log in to get the status of a request by member ID or reference ID. Information is available to the ordering provider, servicing provider, and facility listed on the request (by TIN).
Note: We typically respond to your original request within 5 business days. It may take up to 15 days if we need additional information. As soon as we make a decision, we'll fax it to you. If we deny the request, we'll mail a detailed letter to you and the member.
You can change a review request by fax at 800-843-1114. Be sure to include the reference ID number.
Visit AIM Specialty Health or call 866-666-0776.
Visit eviCore healthcare.
Fax your request to 800-843-1114. Be sure to use the appropriate form.
Durable medical equipment (DME) requestProvider-administered infusion drugs request
Use the general prior auth request form for skilled hourly home health care, non-specific/unlisted codes, or requests with more than 10 procedure codes. Home health no longer requires review.
View prior auth details for admission and discharge notification.
We require review for major procedures or services that could be a health and safety issue for our members. This includes most planned inpatient services, some planned outpatient services, some durable medical equipment, and some in-office pharmacy services including injectables, IVs, and biologics.
Some common services that require prior authorization include:
Use our Rx search tool to see if a drug requires prior authorization.
If an emergency prevents you from getting prior authorization, you must notify us within 48 hours following onset of treatment, or as soon as is reasonably possible.
We know situations arise that may make it impossible for you to get prior authorization before treating a patient, or to notify us within 24 hours of admission. In these situations, please contact us before submitting a claim. Follow the recommended practices detailed in the extenuating circumstances policy so that the claim isn't automatically denied.
Please submit dental pre-determination requests as you would normally submit a claim, by electronic data interchange (EDI), or by mail to:
P.O. Box 91059
Seattle, WA 98111-9159
Contracted providers outside of Washington and Alaska can submit reviews by logging in to the Blue plan's website in your service area. View prior auth info for out-of-area providers.
On behalf of Premera Blue Cross, AIM Specialty Health (AIM) is an independent company that manages imaging services for Premera.
On behalf of Premera Blue Cross, eviCore healthcare (formerly known as CareCore National) is an independent company managing outpatient rehabilitation services for Premera providers.