General authorization process and notifications — review, written authorizations, and responsibilities

We review certain outpatient and inpatient services for medical necessity and send written authorizations to the member, the ordering clinician, and the servicing provider or facility when approved; denials are communicated to the same parties. Authorization requirements listed do not always reflect a subscriber's benefits — always check eligibility and benefits before providing services.

eTools for submitting authorization requests — Authorization Manager and Pre-Service Review guidance

Use Authorization Manager to submit authorization requests for in-state Blue Cross Blue Shield of Massachusetts members; use the Pre-Service Review eTool for BlueCard (out-of-state) members. For Medicare Advantage members, use of Authorization Manager is encouraged but not required.

• In-state BCBSMA: eTools > Authorization Manager at bluecrossma.com/provider.
• BlueCard (out-of-state): eTools > Pre-service review for BlueCard members; enter the member's three-character prefix to be routed to their local plan's tool.

Service- and product-specific prior authorization requirements (summary)

Prior authorization requirements vary by service and product (Commercial HMO/POS, PPO/EPO, Indemnity, Medicare HMO/PPO, FEP); refer to footnotes and applicable medical policies for service- and product-specific rules and vendor routing.

• Certain ambulatory surgical procedures and outpatient services require prior authorization per referenced medical policies (e.g., Medical Policy #072 for Commercial, #132 for Medicare Advantage).
• Cancer care and some chemotherapy/immunotherapy services require prior authorization through Carelon when indicated.
• Genetic testing and other specialized services may require authorization via Carelon per product.
• FEP has specific prior approval processes and references at FEPblue.org.

Special authorization rules for network type and therapy visits

For managed care, EPO and Blue High Performance Network plans, authorization is required for visits to non-contracted providers using the out-of-network request form. For Medicare Advantage HMO/PPO, authorization is required for the initial 16 PT/OT visits; FEP has combined limits for rehab therapies.

• Non-contracted provider visits: submit initial authorization using the Out-of-Network Request Form.
• Medicare Advantage: authorization required for the initial 16 visits for PT/OT.
• FEP: benefit limits apply for physical, occupational and speech therapy combined.

High-technology radiology (HTR) prior authorization process — vendor routing and component imaging notes

When high-technology radiology (HTR) prior authorization is required, request it through the vendor Carelon; authorization is not required when the imaging is provided as a component of an inpatient admission, ER visit, observation, or outpatient surgery.

• Check authorization requirements using Authorization Manager and perform an eligibility inquiry with the service type 'MRI/CT Scan.'
• If the MRI/CT Scan area indicates authorization is required, request prior authorization via Carelon for specified HTR services (CT, MRI, PET, nuclear medicine, CT colonography, LDCT, coronary CTA, etc.).
• FEP: prior approval is required for FEP Blue Focus only (per HTR notes).

High-technology Radiology prior authorization process — request through Carelon and verification steps

When required, request prior authorization for high-technology radiology through Carelon and verify the need using Authorization Manager and an eligibility inquiry specifying 'MRI/CT Scan.' Authorization is not required for high-tech imaging provided as a component of inpatient admission, ER visit, observation, or outpatient surgery.

• Services that may require prior authorization include CT, MRI (fMRI, MRA, MRS), PET, nuclear cardiac studies, CT/PET fusion, diagnostic and screening CT colonography, and LDCT.
• Perform eligibility check with service type 'MRI/CT Scan' to determine authorization requirement before submitting to Carelon.

Sleep management and speech therapy prior authorization — FEP-specific prior approval and fax routing

For sleep studies under FEP Standard and Basic options, prior approval is required for outpatient (non-home) studies; fax prior authorization requests to 1-888-282-1315. Authorization is required for out-of-network speech therapy; use the Out-of-Network Request Form.

• Sleep Management (FEP): prior approval required for outpatient sleep studies (non-home). Fax requests to 1-888-282-1315.
• Speech therapy: authorization required for out-of-network care; submit via the Out-of-Network Request Form.

Acute Residential Treatment authorization/notification — pediatric and adult requirements

Acute Residential Treatment (ART): for children and adolescents (22 years or less) notification within 72 hours of admission is required; for adults (23 years or above) prior authorization is required for psychiatric ART. For substance use ART, notification within 72 hours is required for both children/adolescents and adults.

• Pediatric ART (≤22 years): notify Blue Cross within 72 hours of admission.
• Adult psychiatric ART (≥23 years): obtain prior authorization before admission.
• Substance use ART (all ages): notification within 72 hours of admission is required.

Eligibility and network limitations — check member eligibility; Medicare PPO in‑network requirement

Always check member eligibility and benefits before providing services; authorization requirements listed may not reflect a subscriber's benefits. For Medicare PPO Blue, when authorization is required it must be obtained for in-network providers only.

• Verify eligibility and benefits using an eTool prior to service.
• When Medicare PPO Blue requires authorization, the authorization applies to in-network providers only.