How to submit authorization requests

Use Authorization Manager (bluecrossma.com/provider > eTools > Authorization Manager) to submit prior authorization requests for in-state BCBSMA members. For out-of-state Blue (BlueCard) members, use the Pre-Service Review eTool and enter the member's three-character prefix from the ID card to be routed to their plan's Electronic Provider Access tool. For in-state providers seeing FEP members who live out of state, fax the request — these cannot be submitted using Authorization Manager. For Medicare Advantage members, use of Authorization Manager is encouraged but not required.

• In-state BCBSMA members: Authorization Manager via bluecrossma.com/provider > eTools > Authorization Manager.
• BlueCard (out-of-state Blue) members: Pre-Service Review eTool; enter member three-character prefix from ID card to route to local plan EPA.
• In-state providers for out-of-state FEP members: fax requests — cannot use Authorization Manager.
• Medicare Advantage: use of Authorization Manager encouraged but not required.

Interpreting the authorization table ('Yes' entries and Medicare PPO)

'Yes' in the authorization/notification tables means authorization or notification is required for some members; refer to table footnotes for details. Note that for Medicare PPO Blue, when authorization is required it applies in-network only.

• 'Yes' indicates requirement for some members — check footnotes for exceptions and details.
• Medicare PPO Blue: required authorizations apply in-network only.
• Authorization table entries may not reflect a subscriber's individual benefits — verify eligibility.

Prior authorization required for specific procedures and cancer care

Prior authorization is required for certain ambulatory surgical procedures per BCBSMA medical policies; refer to Medical Policy #072 for the commercial outpatient prior authorization code list and Medical Policy #132 for Medicare Advantage outpatient procedure management. When cancer outpatient care authorization is required for chemotherapy, immunotherapy, certain supportive medications, or radiation services, request prior authorization through the vendor Carelon and consult related medical policies.

• Ambulatory surgical procedures: prior authorization required per medical policies — see Medical Policy #072 (Commercial) and #132 (Medicare Advantage).
• Cancer care (outpatient): when required, request prior authorization through Carelon Medical Benefits Management for commercial and Medicare Advantage members; FEP has separate requirements at FEPblue.org.
• Check eTools for specific authorization requirements and policy references.

Product mapping in authorization/notification tables

The authorization/notification tables map each listed service to product types: Service 1 = Commercial HMO/POS, 2 = PPO/EPO, 3 = Indemnity, 4 = Medicare Advantage HMO Blue, 5 = Medicare Advantage PPO Blue, and 6 = FEP. Use the table and footnotes to determine whether authorization or notification is required for a given service and product.

• Service numbering: 1=Commercial HMO/POS, 2=PPO/EPO, 3=Indemnity, 4=Medicare HMO, 5=Medicare PPO, 6=FEP.
• Consult table footnotes for product-specific exceptions and coverage notes.

Verify eligibility; Medicare PPO authorization applies in-network only

Always check member eligibility and benefits using an eTool before providing services; authorization requirements listed in the tables may not reflect a subscriber's specific benefits. For Medicare PPO Blue, remember that when authorization is required it applies in-network only.

• Verify eligibility and benefits via eTools prior to delivering services — table entries are general and may not match the subscriber's plan.
• Medicare PPO Blue: required authorizations are in-network only.

Age-based notification and prior authorization timing

Follow the age-based timing in the tables: for children and adolescents (22 years of age or less), notification within 72 hours of admission is required for the listed services; for adults (23 years or older), prior authorization or the adult-specific timing noted in table footnotes applies.

• Children/adolescents (≤22 years): notification within 72 hours of admission for applicable services.
• Adults (≥23 years): prior authorization is required for certain services as specified in the table and footnotes.

FEP prior approval and where to find FEP-specific policies

For FEP Blue Focus products, prior approval is required. Refer to FEP-specific medical policies at FEPblue.org for details and, for certain FEP prior approval requests, contact Clinical Intake at 1-800-689-7219 as indicated in the FEP guidance.

• FEP Blue Focus: prior approval required; view FEP-specific medical policies at FEPblue.org.
• Some FEP requests (per cancer care guidance) direct providers to FEPblue.org or to contact Clinical Intake at 1-800-689-7219 for prior approval instructions.
• In-state providers seeing out-of-state FEP members may need to fax requests instead of using Authorization Manager.