CurrentBlue Cross Blue Shield - MassachusettsPolicy MPC_112015-3Q

Authorization requirements by product

This document lists Blue Cross Blue Shield of Massachusetts authorization and notification requirements across products for a range of outpatient and inpatient services; it applies to providers submitting requests and to members whose coverage may require prior authorization. Always verify member eligibility and benefits before providing services.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyAuthorization requirements by product

Policy CodePolicy MPC_112015-3Q

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse Authorization Manager (in-state) or Pre-Service Review eTool (BlueCard/out-of-state) to verify eligibility and submit prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

eToolseTools referenced

CarelonCarelon vendor

SleepSleep management prior approval

FEP notesFEP-specific notes

Authorization and Notification by Service and Product

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Service-by-product authorization summary

Authorization/notification required status varies by service and product; 'Yes' in the table means authorization or notification is required for some members—refer to footnotes and product-specific medical policies.

ALL of the following

Acute care services
- Acute Rehab: authorization required across all products (Commercial HMO/POS, PPO/EPO, Indemnity, Medicare HMO, Medicare PPO, FEP).
  See service table.
- Acute Inpatient - Psychiatric Disorders: authorization required for Commercial, PPO, Indemnity, Medicare HMO and PPO, and FEP (Yes across listed products).
  See behavioral health section.
Ambulatory and outpatient procedural services
- Ambulatory Surgical Procedures: prior authorization required for Commercial and PPO/EPO; may require medical policy review or different handling for Indemnity and FEP per table footnotes.
  Refer to medical policies for procedure-level requirements.
- High-technology Radiology (MRI/CT/PET/nuclear) elective outpatient imaging: authorization required for Commercial and Medicare Advantage when performed electively in outpatient setting; not required when imaging is part of inpatient admission, ER visit, observation, or outpatient surgery.elective, outpatient only
  Request prior authorization through vendor Carelon when required.
Rehabilitation and therapy services
- Physical and Occupational Therapy (outpatient short-term rehabilitation): authorization required for Commercial, PPO/EPO, and Medicare Advantage HMO/PPO; not required for Indemnity and FEP per table.
  Medicare Advantage initial visit threshold applies (see separate threshold rules).
- Speech Therapy (outpatient): table indicates No authorization required across listed products in table entries shown.
  Out-of-network speech therapy does require authorization via Out-of-Network Request Form.
Behavioral health levels of care
- Acute Residential Treatment (ART) - Psychiatric Disorders: authorization/notification required for many commercial and PPO products; Not covered for some Medicare Advantage products; FEP may require authorization per table.
  Children/adolescents: notification within 72 hours for ART admissions; adults: authorization or notification varies—see behavioral health notes.
- Acute Residential Treatment (ART) - Substance Use Disorders: authorization/notification varies by product; some Medicare Advantage products show Not covered.
  Refer to ART-specific footnotes for notification timelines and coverage exclusions.
Specialty mental health procedures
- Esketamine (Spravato) and Intravenous Ketamine for mental health: covered (Yes) for Commercial, PPO/EPO, Indemnity, and Medicare Advantage HMO/PPO; Not covered for FEP.
  See procedural technologies coding group for additional details.
- Transcranial Magnetic Stimulation (TMS): covered (Yes) for Commercial, PPO/EPO, Indemnity, and Medicare Advantage HMO/PPO; Not covered for FEP.
  Coverage varies by product—check member benefits.
Other services referenced in table
- Durable Medical Equipment: authorization required for Commercial, PPO/EPO, Medicare Advantage HMO/PPO, and FEP; may vary for Indemnity.
  Some DME items (e.g., sleep therapy devices) require initial and ongoing authorizations.
- Cancer care (outpatient medical and radiation oncology): authorization required for Commercial and PPO/EPO and for Medicare Advantage products per table; Indemnity may show No.
  Certain oncology therapies have footnote-driven pathways (e.g., gene/CAR T-cell therapy).

ALL of the following

Ambulance (Non-urgent): authorization required for Commercial and certain Medicare products; Not covered for FEP in the table entries shown.
See ambulance footnote for details.

ALL of the following

Applied Behavior Analysis (ABA): covered (Yes) for Commercial and PPO/EPO and some Indemnity; Not covered for certain Medicare Advantage products; FEP shows Yes.
Coverage depends on product.

Selected coverage stance and authorization requirements

Authorization/notification requirements vary by service and product; 'Yes' indicates some members require authorization/notification; 'Not covered' entries indicate noncoverage for specific products.

ALL of the following

Acute Inpatient - Psychiatric Disorders: authorization required (Yes) for Commercial, PPO/EPO, Indemnity, Medicare Advantage HMO and PPO, and FEP per the product table.
Footnote references may apply.

ALL of the following

Acute Residential Treatment (ART) - Substance Use Disorders: Commercial, PPO/EPO, Indemnity, and FEP = Yes; Medicare Advantage HMO and PPO = Not covered per table entries.

ALL of the following

Intensive Community-Based Treatment (ICBT) for Children & Adolescents: Yes for many commercial products (Commercial HMO/POS, PPO/EPO, Indemnity); Not covered for some Medicare Advantage products and FEP as indicated.

Procedure and Service Code Lists, Visit Thresholds

Ambulatory Surgical Procedures prior auth code listmixed

No codes listed

High-technology Radiology (HTR) servicesmixed

Computed Tomography	Computed Tomography
Nuclear cardiac studies	Nuclear cardiac studies
Nuclear Medicine	Nuclear Medicine
MRI	MRI, fMRI, MRA and MRS
MRA Angiography	MRA Angiography
Coronary CT and Coronary CTA	Coronary CT and Coronary CTA
CT/PET Fusion	CT/PET Fusion
PET scans	PET scans
Diagnostic and screening CT colonography	Diagnostic and screening CT colonography
Low Dose CT Scan (LDCT)	Screening test, Low Dose CT Scan (LDCT) for lung cancer

Mental health procedural technologiesmixedCovered

Esketamine Nasal Spray (Spravato)	Esketamine Nasal Spray (Spravato) - Covered for Commercial HMO/POS, PPO and EPO, Indemnity, Medicare Advantage HMO and Medicare Advantage PPO; Not covered for FEP
Intravenous Ketamine	Intravenous Ketamine for Mental Health Conditions - Covered for Commercial HMO/POS, PPO and EPO, Indemnity, Medicare Advantage HMO and Medicare Advantage PPO; Not covered for FEP
Transcranial Magnetic Stimulation (TMS)	Transcranial Magnetic Stimulation (TMS) - Covered for Commercial HMO/POS, PPO and EPO, Indemnity, Medicare Advantage HMO and Medicare Advantage PPO; Not covered for FEP

inv-06: Initial visit authorization threshold for Medicare Advantage PT/OT

ThresholdMedicare Advantage: authorization required for the initial 16 outpatient physical therapy (PT) and occupational therapy (OT) visits.

Applies toMedicare Advantage HMO and PPO members as noted in the policy table.

Provider actionSubmit prior authorization after the initial 16 visits are reached (verify via Authorization Manager).

inv-07: SNF FEP benefit limit

Benefit limitFEP Blue Standard members without Medicare Part A: 30-day annual Skilled Nursing Facility (SNF) benefit.

Applies toFederal Employee Program (FEP) Blue Standard members who do not have Medicare Part A.

Provider actionConfirm member’s Medicare Part A status and FEP benefit before admitting to a SNF; check eligibility for remaining days.

How to Request Authorization and Operational Rules

Note

Overview of authorization process

We review certain outpatient and inpatient services to determine medical necessity. If approved, we send a written authorization to the member, ordering clinician, and servicing provider or facility. When we deny coverage, we notify the member, ordering clinician, and servicing provider. Authorization requirements listed do not always reflect a subscriber's benefits — always verify eligibility and benefits before providing services.

Authorization approvals and denials are sent in writing to the member, ordering clinician, and servicing provider or facility.
Always verify member eligibility and specific benefit coverage prior to scheduling or delivering services.

Note

eTools and submission routing

Use Authorization Manager to check specific authorization requirements and submit requests for in‑state Blue Cross Blue Shield of Massachusetts members. For out‑of‑state (BlueCard) members, use the Pre‑Service Review eTool and enter the member's three‑character prefix to route to the member's local Blue plan EPA tool. For Medicare Advantage members, Authorization Manager use is encouraged but not required.

In‑state Blue Cross MA members: use Authorization Manager (bluecrossma.com/provider > eTools > Authorization Manager).
BlueCard/out‑of‑state members: use Pre‑Service Review eTool (bluecrossma.com/provider > eTools > Pre‑service review for BlueCard members).
If out‑of‑state, use the local Blue plan's Electronic Provider Access (EPA) tool.
For Medicare Advantage members, Authorization Manager is encouraged but not required.

Prior Authorization

Authorization requirements by service and product

The table of authorization or notification requirements indicates which services may require prior authorization or notification by product. 'Yes' entries may have footnote routing (see items) that specify the exact prior authorization pathway, vendor, or forms to use. Authorization requirements may be product‑specific (Commercial HMO/POS, PPO/EPO, Indemnity, Medicare HMO, Medicare PPO, FEP). Remember: Medicare PPO Blue — when authorization is required, it is required in‑network only.

Follow the product column to determine whether authorization/notification is required for a given service; refer to the applicable footnotes for routing and vendor details.
Examples of services that commonly require prior authorization: ambulatory surgical procedures, durable medical equipment (select items), genetic testing, high‑technology radiology, cancer care (outpatient oncology), sleep management studies and durable medical equipment, transplants, acute rehab, skilled nursing, and others listed in the table.
Authorization requirements do not replace benefit verification — check eligibility and benefits before providing services.

Prior Authorization

Footnote‑specific prior authorization pathways

Footnotes in the product table indicate special prior authorization pathways or vendor requirements. Follow these footnotes when applicable.

Ambulance (non‑urgent): see footnote for coverage specifics and whether authorization is required by product.
Ambulatory Surgical Procedures: prior authorization required for certain procedures per medical policy. Refer to Medical Policy #072 (Commercial) and Medical Policy #132 (Medicare Advantage) or FEP resources.
Assisted Reproductive Technology (ART): refer to Assisted Reproductive Services (Medical Policy 086) and Preimplantation Genetic Testing (088); coverage varies by product.
Cancer care (outpatient oncology) and CAR T/gene therapies: prior authorization required; follow medical policy and vendor routing.
Genetic Testing: when required, request prior authorization through Carelon for Commercial HMO/POS, PPO, and Medicare Advantage; FEP and other products have separate instructions.
Durable Medical Equipment: only select items require authorization (e.g., sleep therapy devices, power wheelchairs); see medical policies.
High‑technology Radiology (HTR): see HTR block for Carelon routing and Authorization Manager checks.
Acute Residential Treatment (ART) and Acute Residential for Substance Use Disorders: footnotes specify notification vs prior authorization by age and product — see ART block.

Denial Risk

Out‑of‑network and visit‑limit authorization rules

Out‑of‑network and visit‑limit authorization rules apply for certain products and services. Follow product and network rules when requesting authorizations for non‑contracted providers or when benefit visit limits apply.

For managed care, EPO and Blue High Performance Network plans: authorization is required for all visits to a non‑contracted provider. The PCP or specialist must submit the initial authorization using the Out‑of‑Network Request Form.
For Medicare Advantage HMO/PPO: authorization is required for the initial 16 visits for therapy services where noted (example: outpatient PT/OT).
FEP: benefit limits may apply for combined PT/OT/Speech therapy services; confirm limits in the member's Service Benefit Plan brochure.
Medicare PPO Blue: when authorization is required, it is required in‑network only.

Prior Authorization

High‑technology Radiology (HTR) prior authorization process

High‑technology radiology services (MRI, CT, PET, nuclear cardiac tests and related advanced imaging) require prior authorization when indicated by product and service type. Use Carelon for prior authorization requests and check Authorization Manager to confirm requirement.

When required, request prior authorization through Carelon for Commercial and Medicare Advantage members.
Do not request authorization for HTR performed as a component of an inpatient admission, emergency department visit, observation stay, or outpatient surgery.
Perform an eligibility inquiry in Authorization Manager using service type 'MRI/CT Scan' — if results indicate authorization is required, submit a prior authorization.
Services that may require prior authorization include: Computed Tomography; Nuclear cardiac studies; Nuclear Medicine; MRI, fMRI, MRA, MRS; MRA angiography; Coronary CT and Coronary CTA; CT/PET fusion; PET scans; diagnostic and screening CT colonography; Low Dose CT (LDCT) lung cancer screening when indicated.
FEP: prior approval is required for FEP Blue Focus only.

Prior Authorization

Speech Therapy Out‑of‑Network authorization

Speech therapy authorizations differ by in‑network vs out‑of‑network and by product. Use the specified form for out‑of‑network requests.

Outpatient speech therapy: authorization is required for out‑of‑network care. Use the Out‑of‑Network Request Form to submit requests.
Check product‑specific benefit limits (e.g., FEP combined PT/OT/Speech limits) and Medicare Advantage initial visit rules where applicable.

Prior Authorization

Acute Residential Treatment authorization/notification rules

Acute Residential Treatment (ART) and Acute Residential for Substance Use Disorders have age‑dependent notification and authorization rules. Follow the timelines below when admitting members.

Acute Residential Treatment — Psychiatric Disorders: For children and adolescents (22 years of age or less), notify within 72 hours of admission. For adults (23 years and older), prior authorization is required before admission.
Acute Residential Treatment — Substance Use Disorders: For children and adolescents (22 years or less), notify within 72 hours of admission. For adults (23 years and older), notify within 72 hours of admission (prior authorization may vary by product).
Ensure the correct routing (notification vs prior authorization) based on member age and product; consult the product table footnotes for product‑specific rules.

Key Terms and Tools

inv-18: Authorization Manager

NameAuthorization Manager

PurposeBlue Cross Blue Shield of Massachusetts eTool used to verify member eligibility and determine specific authorization requirements for in-state members.

AccessLog in at bluecrossma.com/provider and go to eTools > Authorization Manager to submit and check authorizations for in-state members.

inv-19: Pre-Service Review

NamePre-Service Review eTool

PurposeRouter tool for BlueCard/out-of-state members that forwards authorization requests to the member’s local Blue plan Electronic Provider Access tool.

AccessLog in at bluecrossma.com/provider and go to eTools > Pre-service review for BlueCard members; enter the member’s three-character prefix to be routed appropriately.

inv-20: High-technology Radiology (HTR)

DefinitionHigh-technology Radiology (HTR)

Included modalitiesComputed Tomography (CT) including Coronary CT/CTA and CT/PET fusion; Magnetic Resonance Imaging (MRI) including fMRI, MRA, MRS and MRA angiography; Positron Emission Tomography (PET); Nuclear medicine and nuclear cardiac studies; Diagnostic and screening CT colonography; Low Dose CT (LDCT) screening for lung cancer.

Authorization noteWhen required, prior authorization must be requested through vendor Carelon; authorization is not required when imaging is part of an inpatient admission, ER visit, observation, or outpatient surgery.

inv-21: ICBT

DefinitionIntensive Community-Based Treatment (ICBT)

Included servicesIntensive Care Coordination (ICC); In-Home Therapy (IHT); In-Home Behavioral Services (IHBS); Therapeutic Mentoring (TM); Family Support & Training (FS&T).

Coverage noteSome self-insured employers may not cover ICBT; verify member benefits prior to providing services.