Blue cross blue shield federal prior authorization phone number

Prior Approval

As part of our Patient Safety and Quality Monitoring (PSQM) program (see above), you must make sure your physician obtains prior approval for certain prescription drugs and supplies in order to use your prescription drug coverage. In providing prior approval, we may limit benefits to quantities prescribed in accordance with generally accepted standards of medical, dental, or psychiatric practice in the United States. Prior approval must be renewed periodically. To obtain a list of these drugs and supplies and to obtain prior approval request forms, call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077. You can also obtain the list and forms through our website at www.fepblue.org. Please read Section 3 for more information about prior approval.

Notes:

• Updates to the list of drugs and supplies requiring prior approval are made periodically during the year. New drugs and supplies may be added to the list and prior approval criteria may change. Changes to the prior approval list or to prior approval criteria are not considered benefit changes.
   
• If your prescription requires prior approval and you have not yet obtained prior approval, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.
   
• It is your responsibility to know the prior approval authorization expiration date for your medication. We encourage you to work with your physician to obtain prior approval renewal in advance of the expiration date.

For Washington and Alaska

Prior approval lists by plan

Standard and Basic Option prior approval list
FEP Blue Focus prior approval list

Prior approval/pre-service request forms for services provided in Alaska or Washington only

Alaska prior approval form
Washington prior approval form
Alaska precertification/concurrent review request form
Washington precertification/concurrent review request form

Applied behavior analysis (ABA) prior approval forms

Alaska ABA prior approval form
(Eastern) Washington ABA prior approval form

Durable medical equipment (DME) prior approval forms

Alaska DME prior approval form
Washington DME prior approval form

For services outside Alaska or Washington

Please contact the local Blue plan where the service is provided.

For more information, call 877-342-5258, option 3.

The “Prior authorization list” is a list of designated medical and surgical services and select prescription Drugs that require prior authorization under the medical benefit. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to payment authorization.

Members and providers are encouraged to obtain prior authorization and may call Customer Service to inquire about the need for prior authorization. While the list below covers the medical services, drugs, and procedures that require authorization prior to rendering; Blue Shield may require additional information after the service is provided.

If further information is required to process the payment Blue Shield’s Claims department will reach out and will request the specific information at that time. Before providing service please contact Customer Service or access the provider connection website to verify the service is a covered benefit.

Blue Shield of California providers

Prior authorization for the services listed below is highly recommended. For more information on obtaining prior authorization review refer to your provider manual. If authorization was not obtained prior to the service being rendered, the service will likely be reviewed for medical necessity at the point of claim.

Please include medical records when you are ready to submit for claim payment, review our medical policies, and verify the service is a covered benefit online through our provider connection website or contact Customer Service. If prior authorization was obtained and you are submitting an offline (i.e. paper) claim, remember to attach a copy of the prior authorization letter.

Prior authorization requirements for out-of-area Blue Plan members

Providers can view medical policy and general prior authorization requirements for patients who are covered by an out-of-area Blue Plan, using our Medical policy and general prior authorization requirements for out-of-area members tool.

Blue Shield of California Promise Health Plan providers

See the list of the designated medical and surgical services and select prescription drugs, which require prior authorization under a Blue Shield of California Promise Health Plan medical benefit.

Advanced imaging services

Prior authorization medical necessity reviews are highly recommended for certain non-emergency outpatient advanced imaging procedures (CT, MRI, MRA, PET, cardiac nuclear medicine) for Administrative Services Only (ASO), HMO Direct Contracting and PPO plans. Review requests for services are performed by National Imaging Associates. Visit the NIA website to use this service, or call (888) NIA-BLUE (642-2583).

Spine surgery and pain management services

Prior authorization medical necessity reviews are highly recommended for certain spinal procedures (spinal surgery, spinal injections, spinal implants) for Administrative Services Only (ASO), HMO Direct Contracting, and PPO plans. Review requests for services are performed by National Imaging Associates. Visit the NIA website to use this service, or call (888) NIA-BLUE (642-2583).

Federal Employee Program

Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements. For both outpatient procedures and treatment requiring an inpatient stay, call (800) 633-4581 to obtain prior authorization.

Out-of-area providers

If you are an Out-of-area provider treating a Blue Shield of California member, contact the customer service phone number on the back of the member’s card to verify if the service is a covered benefit under the plan and to verify if prior authorization is required.

Prior authorization list (Medical)

The document below lists prior authorization codes for Blue Shield (including Medicare 65+).

View Blue Shield Prior Authorization list (PDF, 107 KB)

Prior authorization information for medications

Prior Authorization information for medications can be found here for the following plans: Medicare Plans [Part D drug list, Part B PPO], Medical Benefit Commercial Plan, Medical Benefit PHP Medi-Cal Plan, and Pharmacy Benefit Commercial Plan