Services that need approval

Depending on what type of plan you have, we may need to review and approve some of your health care services before we cover them. We call this prior authorization.

If you need preapproval, your doctor or health care professional will request a review on your behalf. Once we get the request, we'll begin the review process. So, it's important they send us all the materials we need for your review, up front.

If you're looking for more information about prescription drug prior authorization, read Why do I need prior authorization for a prescription drug?

There are four types of review for health care services:

  • Preservice non-urgent review: When you need to get a certain health care service, but it isn't urgent. It can take up to 15 days for us to make our decision. This is the most common type of review.
  • Preservice urgent review: When you need to get a certain health care service as soon as possible, but it isn't an emergency. It can take up to three days for us to make our decision.
  • Urgent concurrent review: When you're already getting care and you can't wait to get approval for it. This often happens with trips to the emergency room. It can take up to 24 hours for us to make our decision.
  • Postservice review: When you've already gotten the care you need and you request approval for it. It can take up to 30 days for us to make a decision.

If you disagree with our decision, you can appeal.

You'll need to be sure that your plan covers your health care services and that your coverage is active at the time you receive treatment. If you don't get prior authorization when it's needed, we might not pay your claim. When we review your services, that doesn't guarantee payment of your claims. Sometimes, we need to review to be sure the service is medically necessary and appropriate for your situation.

Here are some services that need approval. This is not a full list. 

  • Some radiology services: 
    • CT
    • CTA
    • Echocardiology
    • MRI
    • MRA
    • MRS
    • Nuclear cardiology
    • PET
    • QCT bone densitometry
  • Inpatient care:
    • Acute
    • Lumbar spinal fusion
    • Mental health care including residential psychiatric admissions
    • Substance use disorder treatment
  • In-lab sleep studies
  • Interventional pain management
  • Skilled nursing facility care
  • Human organ transplant services
  • Radiation therapy (oncology)
  • Rehabilitation therapy
  • Applied behavioral analysis
  • repetitive Transcranial Magnetic Stimulation (rTMS)
  • Gender reassignment surgery
  • Freestanding substance use disorder facilities

Blue Care Network HMO and POS members

If you have an HMO or POS plan, there are some additional services you'll need approval for. Here are some examples:

  • Procedures that may be cosmetic, such as removing scars or excess tissue from your eyes or abdomen
  • Physical therapy, speech therapy and occupational therapy
  • Weight-reduction procedures
  • Bone marrow transplants
  • Infertility services
  • Breast reduction
  • Durable medical equipment
  • Services from out-of-network physicians or health care professionals for HMO plans
  • Procedures that may be experimental or investigational
  • Genetic testing
  • Outpatient mental health and substance use disorder services from out-of-network physicians or providers
  • Sleep studies (any outpatient setting)
  • Cardiology procedures
  • Radiation therapy
  • Spine injections
  • Knee arthroscopies