Prior authorization
View current prior authorization and notification requirements before using the prior authorization lookup tool.
About prior authorization
Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) requires prior authorization (PA) for some covered admissions, continued stays, services, procedures, drugs and medical devices before they’re covered.
Prior authorization is a review and approval before a service happens to determine whether it’s medically necessary and appropriate. Prior authorization needs vary by the type of health plan the member has.
Getting a prior authorization does not guarantee coverage. Whether or not authorization is required, coverage depends on the relevant medical policy or evidence-based coverage criteria. Each time a member seeks services, you also need to verify benefits and eligibility. All applicable terms and conditions of the member’s plan, including coverage exclusions, network requirements, deductibles, copayments and coinsurance apply with an authorization.
Step 1: Determine whether prior authorization is needed
Acute hospital care
- Admission: Notify Blue Cross about all planned and unplanned admissions. Include medical records that support the need for inpatient care. Some hospital admissions require plan approval and will be reviewed for medical necessity. Note: Observation care (also known as 23-hour observation) does not require notification or approval.
- Continued stay: Notify Blue Cross when a member stays inpatient longer than planned or approved. Include medical records that support the need for continued stay.
- Discharge from hospital: Notify Blue Cross when a member is discharged from the acute level of care. Include the discharge summary with the date they were discharged and where they went.
All other care
For other services, procedures, drugs and medical devices, prior authorization needs vary by the type of health plan the member has.
BlueCard members from other Blue Plans
Use the Blue Cross Blue Shield Plan’s Electronic Provider Access router tool to access other Blue Plan’s provider portals for prior authorization reviews for BlueCard members, including Alternative Health Plan Portfolio members.
Enter the member’s three-character prefix to be routed to their Blue Plan’s EPA page. You can access the Blue Plan’s prior authorization information and any online pre-service review processes they offer.
Federal Employee Program (FEP)
Use the applicable Service Benefit Plan brochure to determine whether authorization is required for a service or group of services.
- “Section 3: How You Get Care”
Post-acute facility care
- Admission: Post-acute care includes acute rehabilitation, long term acute care, skilled nursing facility care, and residential treatment. All post-acute admissions require plan approval and will be reviewed for medical necessity. Submit a prior authorization request with medical records that support the need for the requested level of care.
- Continued stay: All continued stays in a post-acute facility require plan approval. Submit a prior authorization request with medical records that support the need for additional days at the requested level of care.
- Discharge from a post-acute facility: Notify Blue Cross when a member is discharged. Include the discharge instructions with the date they were discharged and where they went.
Medical Policy and Pre-Certification / Authorization Router
View an out-of-state Blue Plan's medical policy or general pre-certification / pre-authorization information.
Commercial, Medicare, Minnesota Health Care Programs (MHCP) and Minnesota Senior Health Options (MSHO) plans
Use this online tool to determine whether authorization is required for a service or group of services. This tool is also available in the Authorizations tool in the Availity Essentials portal.
See the full lists of prior authorization and notification requirements:
- Commercial Prior Authorization and Notification List
- Medicare Advantage Prior Authorization and Notification List
- Platinum BlueSM Medicare Cost Prior Authorization and Notification List
- Minnesota Health Care Programs – MHCP (Families and Children (PMAP), MNCare, MSC+) Prior Authorization and Notification List
- Minnesota Senior Health Options (MSHO) Prior Authorization and Notification List
Step 2: Submit a request for prior authorization (if needed)
Request authorization online
The most efficient way to submit and manage requests for prior authorization is to log in to Availity Essentials.
Blue Cross participating providers are required to use the Availity Essentials portal to submit prior authorization requests, admission notifications and continued stay notifications.
Request authorization by fax
Use the most applicable fax form for the admission, service, procedure, drug or medical device being requested. Fax numbers and mailing addresses are on the forms.
Support resources
Questions about a medical policy or an appeal?
Providers: Call provider service at (651) 662-5000 or 1-800-262-0820.
Members: Call the number on the back of your member ID card or (651) 662-8000 or 1-800-382-2000 (TTY 711) or log in to your member account and send a secure message to customer service.
Acknowledgements:
The five-digit numeric codes that appear on the documents on this site were obtained from the Physician's Current Procedural Terminology, as contained in CPT® 2022, ©2021 American Medical Association.
Current Dental Terminology, as contained in CDT 2022: Dental Procedure Codes, ©2021 American Dental Association. All rights reserved.
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