About Prior Authorization

  • 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.

    How does it work?

    1. Find out if a code needs review

    To see if we require a prior authorization or a pre-service review, check our code list.

    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.

    Types of services

    Advanced imaging and radiation oncology

    AIM logo

    Visit AIM Specialty Health or call 866-666-0776.

    Outpatient rehabilitation

    EviCore logo

    Visit eviCore healthcare.

    Home health, DME, and others

    For home health, durable medical equipment, provider-administered infusion drugs, non-specific/unlisted codes, and requests with more than 10 procedure codes, fax your request to 800-843-1114. Be sure to use the appropriate form:

    Admission and discharge

    View prior auth details for admission and discharge notification.

    Common services that require prior auth

    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:

    • All planned inpatient stays
    • Admission to a skilled nursing facility or rehabilitation facility
    • Admission to behavioral health residential treatment centers
    • Non-emergency and elective air ambulance services
    • Some outpatient services
    • Certain organ transplants
    • Purchase of supplies, appliances, DME, and prosthetic devices over $500
    • Provider-administered drugs

    Pharmacy

    Use our Rx search tool to see if a drug requires prior authorization.

    Emergencies and extenuating circumstances policy

    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.

    Dental providers

    Fax dental pre-determination requests to 425-918-5956, or mail to:

    Dental Review
    P.O. Box 91059, MS-173
    Seattle, WA 98111-9159

    Out-of-area providers

    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.