Prior plan approval

Prior plan approval (also referred to as prior review, prior authorization, prospective review or certification) is the process by which Blue Medicare HMO & Blue Medicare PPO reviews the provision of certain behavioral health, medical services and medications against healthcare management guidelines prior to the services being provided. Inpatient admissions, services and procedures received on an outpatient basis, such as home health services, and prescription medications may be subject to prior plan approval. Reviews are done to confirm the following:

• Member eligibility.
• Benefit coverage.
• Compliance with Blue Medicare medical policy regarding medical necessity.
• Appropriateness of setting.
• Requirements for utilization of in-network and out-of-network facilities and professionals.
• Identification of comorbidities and other problems requiring specific discharge needs.
• Identification of circumstances that may indicate a referral to chronic case management.

For more information about which services require prior plan approval and instructions on how to request prior review, select from the categories below:

Prescription drugs

Other services and procedures - Such as acute inpatient admissions, behavioral health, home health care services, durable medical equipment or certain outpatient surgical procedures.

Skilled Nursing Facility Admissions

Medicare Part B Step Therapy and Prior Authorization Drug List

Diagnostic Imaging Management Programs

• Blue Medicare HMO and PPO - Services such as MRI, CT, PET and nuclear medicine. Diagnostic Imaging Management Program Services will require Prior Approval as of 4/1/2023.
• Experience Health Medicare Advantage ^SM (HMO) - Services such as MRI, CT, PET and nuclear medicine. Diagnostic Imaging Management Program Services will NO LONGER require Prior Approval as of 1/1/2021.

Medical Oncology Program

• Medicare Advantage HMO/PPO and Experience Health Medicare Advantage ^SM (HMO) - code list effective 1/1/2023
• Medicare Advantage HMO/PPO and Experience Health Medicare Advantage ^SM (HMO) - code list effective 10/03/2022

Important note: In case of emergency, prior approval is NOT required. An emergency is an instance in which the absence of medical attention could jeopardize a person's life, health, or ability to regain maximum function, or could subject a person to severe pain.