Prior authorization

We may require prior authorization reviews to confirm:

• Member eligibility

• Benefit coverage

• Compliance with Commercial and Blue Medicare^℠ medical policies regarding medical necessity

• Appropriateness of setting

• Requirements for use of in-network and out-of-network facilities and professionals

• Identification of comorbidities and other problems requiring specific discharge needs

• Identification of circumstances that may indicate:

  • a referral to concurrent review, discharge services, or case management
  • a referral to a second opinion, continuity of care, or case management
  • a referral to chronic case management

• Services on the Prior Authorization Code List that are rendered emergently or urgently during an inpatient admission are still subject to medical necessity criteria.