Some medical services and treatments need to be approved by your health plan as "medically necessary" before you can get them. Your primary care provider (PCP) or other health care provider must get approval from your health plan — this is called “prior authorization.” This process helps make sure you get the care you need, as well as helping to stop fraud, waste, and abuse.
View services requiring prior authorization.
Centers for Medicare & Medicaid Services (CMS) requirement
Every year, Blue Cross Complete must provide data on our website about how many prior authorizations were submitted and approved or denied. The report must be posted by March 31. This reporting is part of CMS Interoperability and Prior Authorization Final Rule CMS-0057-F.
Standard authorizations
* Refers to requests in which a portion of the request was not approved.
** Refers to the additional days allowed to complete the medical necessity review and the determination notice.
Expedited authorizations
* Refers to requests in which a portion of the request was not approved.
** Refers to the additional hours allowed to complete the medical necessity review and the determination notice.