Prior authorization required for commercial members (inpatient & outpatient)

Prior authorization (precertification) is required for services described in this policy for commercial members when performed inpatient or outpatient; submit requests via Authorization Manager and ensure requests meet medical policy guidelines.

• Applies to inpatient services: "precertification/preauthorization IS REQUIRED if the procedure is performed inpatient."
• Applies to outpatient commercial PPO: "Prior authorization is required."
• Requests must meet medical policy guidelines when submitted for commercial members.

Prior authorization required for commercial products — updates & coding clarifications

Prior authorization is required for commercial products and coding clarifications have been made in multiple policy updates; providers should submit prior authorization requests per the payer's Authorization Manager/process.

• Policy history documents repeated clarifications to prior authorization and coding (multiple entries noting clarified coding information and prior authorization clarification for PPO plans).
• Authorization Manager is the submission channel for initial requests.

Fit a standard prosthesis first when benefit is uncertain

For individuals with uncertain potential benefit, fit a standard (non-microprocessor) prosthesis first to determine function before providing a microprocessor-controlled knee.

• Policy: "For individuals in whom the potential benefits of the microprocessor knees are uncertain, individuals may first be fitted with a standard prosthesis to determine their level of function with the standard device."

Use Authorization Manager and follow submission requirements

Providers must follow the policy's authorization and documentation requirements when requesting services; use Authorization Manager and include all required identifiers so requests are processed accurately.

• Enter the facility's NPI or provider ID for where services are performed and the servicing provider's NPI/provider ID (servicing provider, not billing group).
• Consult policy history and guidance for submission processes and coding clarifications.

Submit initial authorization requests via Authorization Manager with facility and servicing provider NPIs

Submit initial authorization requests using Authorization Manager and include the facility NPI/provider ID and the servicing provider's NPI/provider ID to ensure accurate processing.

• Authorization Manager is available 24/7 and is the recommended method to request authorizations, submit clinical documentation, and check case status.
• Enter the servicing surgeon's NPI or provider ID as the servicing provider (not the billing group).

Where to find submission and documentation guidance

Consult the policy's referenced guidance for details on managed care submission rules, indemnity/PPO guidelines, clinical exception processes, and medical technology assessment requirements when preparing documentation.

• Policy history and "Information Pertaining to All Blue Cross Blue Shield Medical Policies" list Managed Care Guidelines, Indemnity/PPO Guidelines, Clinical Exception Process, and Medical Technology Assessment Guidelines as resources.

Denial risk if precertification/prior authorization is not obtained

Failure to obtain precertification/preauthorization for services described in this policy when required for commercial members may result in denial of the claim or reduction of benefits.

• Inpatient services: precertification/preauthorization is required and lack of it may lead to denial.
• Outpatient commercial PPO: prior authorization is required; failure to obtain it risks denial.

Prior authorization requirement history — in place since at least 2009

Prior authorization for commercial products has been required since at least 2009 and the policy history documents multiple updates clarifying prior authorization and coding information.

• Policy history entries span from 2015 through 4/2026 and note repeated clarifications to prior authorization procedures and coding information.
• Explicit statement: prior authorization information clarified for PPO plans (effective 6/1/2022) and earlier entries referencing prior authorization requirements.