In Vitro Fertilization (IVF) coverage request — Provider questionnaire for prior authorization
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This document is a provider-facing IVF coverage determination questionnaire used by Highmark BlueShield to collect patient history, infertility work-up, and proposed treatment for prior authorization decisions. It affects providers seeking coverage approval for IVF for Highmark BCBS members in the governed state(s).
No material clinical or coverage changes in this revision.
Coverage Criteria
The form does not list explicit coverage criteria or detailed medical necessity rules. It is a request form used to initiate an In Vitro Fertilization (IVF) coverage determination and collects clinical information to support that determination, but it does not itself define covered or non‑covered indications.
No supplemental or duplicate coverage criteria are specified on the form. The document asks providers to complete the questionnaire and submit supporting clinical documentation for review, but it does not state additional or alternative coverage requirements or exclusions.
Provider Actions & Submission Requirements
Prior Authorization Required
Prior authorization is required for In Vitro Fertilization (IVF). Providers must fax the completed IVF questionnaire and all supporting clinical documentation to the Medical Management & Policy Department for a coverage determination before services are provided.
- Fax: 800.670.4862 (Delaware)
- Fax: 888.236.6321
- Submit completed questionnaire and supporting clinical documentation for prior authorization
Provider Submission Checklist (Action Required)
Urgent provider instruction: ensure the provider signature and contact information (physician name, office phone, BCBS Provider ID) are included on the submitted form. Missing signature or provider identifiers may delay review.
- Include: physician name and address, Blue Cross Blue Shield Provider ID, office phone, person completing form, and signature
Required Documentation
The following documentation is required with the submission: completed IVF questionnaire, brief patient history, infertility work-up results (tests and results), proposed treatment plan, prior treatments/medications/surgeries to date, and specification of the cause of infertility. Answer specific form questions (e.g., prior tubal ligation, spouse vasectomy, BCBS participation).
- Completed IVF questionnaire
- Brief patient history (including current date)
- Infertility work-up and test results
- List of treatments/medications/surgeries to date
- Proposed treatment and specified cause of infertility
- Responses re: tubal ligation, vasectomy, and BCBS participation
Submission Requirements and Consequences
Failure to submit the completed form and required supporting documentation to the Medical Management & Policy Department via the fax numbers above may result in denial or delay of coverage. Route all prior authorization requests to Claims Review/Medical Management for an IVF coverage determination.
- Consequences: potential denial or delay if documentation not received
- Route to: Medical Management & Policy Department — Claims Review
Definitions
Background
This form is intended to collect the clinical information necessary to evaluate an IVF request for medical necessity. It requests a brief patient history, provider identifiers, results of the infertility work‑up, prior treatments/medications/surgeries, the specified cause of infertility, proposed treatment, and yes/no status for tubal ligation, spouse vasectomy, and Blue Cross Blue Shield provider participation. Providers must sign and include a contact phone number and fax the completed form and supporting documentation to the Medical Management and Policy Department for prior authorization at the listed fax numbers.
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