As part of your coverage, we provide services to help you get high quality care and save money by avoiding unnecessary costs. When you and your doctor are making decisions about your care and how your benefits work, we can help.
Check first: Be sure services that need approval are approved in advance
It's always wise to check your benefits so you know whether a service is covered and confirm that your doctor is in your plan's network. And, for some services, an approval for coverage is also needed. Getting approval in advance is called “prior authorization” or “PA.” If you don't have prior authorization for a service that needs one, the service may not be covered and you may be responsible for the entire cost of your care.
It's easy to find out if approval is needed
Generally, your doctor checks whether a service needs approval for coverage, but you can check online here too. You'll need:
- Your group number from your member ID card
- Date of your procedure
- Name of procedure or procedure code (get from your doctor)
When you look up your procedure, you'll find out if an authorization is needed and what to do next.
About medical policy coverage
Why doesn’t my plan cover a treatment if my doctor recommends it?
Your health plan only covers health services and supplies that are medically necessary.
“Medically necessary” means that you need the health care service or supply to prevent, diagnose or treat an:
- Illness
- Injury
- Condition
- Disease or its symptoms
The service or supply must also meet accepted standards of medicine. If your condition causes harmful symptoms or side effects, your plan considers it medically necessary to treat them as well.
Your health plan may not cover some services and supplies that your doctor recommends.
To find out what your plan covers, check your health plan documents or call the number on the back of your member ID card.
Can I still get a treatment if my plan doesn’t cover it?
If your health plan does not cover a treatment, or if Blue Cross denies coverage, you can choose to receive it and pay for it on your own. Talk with your doctor to find out how much you will need to pay for any service your plan doesn’t cover.
About referrals
Do I need a referral to see a specialist?
Whether you need a referral to see a specialist depends on your plan. Some plans allow you to see any doctor or specialist in your plan network without a referral. If you see a doctor or specialist that is not in your plan network, you may have to pay more. To find a doctor or specialist in your network, use the Find a Doctor tool. Sign in or choose your network name to be sure you’re searching the right network.
If you see a specialist without a referral, be sure to inform your primary care doctor. This information will help your doctor provide the best possible care.
What does a referral include?
A referral typically includes the office visit and any lab work your doctor may request, like x-rays or blood and urine tests. Other services, like shots or minor skin surgery, may require prior authorization.
Important: To find out what services require prior authorization, check your health plan documents, or call the number on the back of your member ID card.
How to appeal
Can I appeal a decision?
Yes, you have the right to appeal a prior authorization decision. Read more below about prior authorization appeals. To make an appeal, see complaints and appeals.
How do I appeal a decision?
You, or a doctor or caregiver acting on your behalf may request an appeal.
You can start an appeal in one of two ways:
- Call the number on the back of your member ID card
- Mail a written appeal
What do I include in an appeal?
- Your name, address and member ID number
- The reasons you disagree with our decision
- Evidence that explains why we should approve your appeal, including medical records, letters from your doctors and other related information. Call your doctor if you need this information or have your doctor submit an appeal for you
If your doctor or caregiver is acting on your behalf, you must sign an authorization form that allows us to release your personal information to your representative. You can complete the authorization for disclosure of health information online.
When do I need to send my appeal?
- We must receive your appeal within 180 days from the time you receive a denial letter from us. If we deny a prior authorization, we send you and your doctor a denial letter
- In most cases, Blue Cross will complete appeal decisions with 15 days. All appeal decisions will be made within 30 days
What if my request is urgent?
If you need to expedite your appeal, call the number on the back of your member ID card. If your request qualifies, we will make a decision and notify you and your doctor within 72 hours after we receive your request.
Typically, a situation is urgent if your health is in serious jeopardy or you will be in severe pain that can’t be controlled while you wait for a decision.
If your request qualifies as urgent, you may also request an external appeal through an Independent Review Organization. For more information on your appeal rights, see your health care documents or call the number on the back of your member ID card.
If you would like to start the appeal process, see complaints and appeals instructions.
How do I get a copy of my records?
To request a free copy of all the documents we use to decide your appeal, call the number on the back of your member ID card. You can also request a list of the diagnosis and treatment codes we use.
Have questions? Give us a call.
Call customer service at the number on the back of your member ID card if you have questions. We can:
- Check your benefits and whether your doctor is in network
- Check whether a prior authorization is needed
- Check the status of a prior authorization