For Providers

Prior Authorization

Services for Which Prior Authorization is Recommended

(Effective 1/1/2010)

Bariatric surgery
Home health (PA must be initiated by the Home Health Care Agency)
Home infusion
Skilled nursing facility admissions
Transplants
- Organ except cornea and kidney
- Bone marrow/stem cell
Deep brain stimulation
Drugs, including but not limited to:
- Growth hormone
- Intravenous immune globulin (IVIG)
Reconstructive procedures and potentially cosmetic procedures, such as:
- Blepharoplasty
- Rhinoplasty
- Panniculectomy
- Scar excision/revision
- Reduction mammoplasty, mastoplexy
Durable medical equipment exceeding $1000
Prosthetics exceeding $5000
Vagus nerve stimulation
Surgical treatment of sleep apnea

NOTE:

MedicareBlue PPO (Regional PPO) has changed the services for which prior authorization is recommended (effective 1/1/10).

Services were removed from retrospective review and will be subject to prior authorization recommendation
We continue to follow Medicare guidelines for services
Authorization for a service, device, or drug does not guarantee coverage but estimates, based on information submitted, whether it meets medical necessity and appropriateness criteria

Please fax, call or write Medical Management to communicate the prior authorization request to us.

Toll free: 1-866-537-7702
TTY users: 1-651-662-1294
8:00 a.m. to 5:30 p.m., Monday – Friday, Central Time
Fax: 1-651-662-9478
Address: P.O. Box 64265, Route R418
St. Paul, MN 55164-0560

The above list is not all-inclusive. The most complete, up-to-date list of services for which prior authorization is recommended can be accessed by calling Provider Services at 1-888-457-3009, 8:00 a.m. to 8:00 p.m., Central and Mountain Time

Access Prior Authorization forms.

March 11, 2010

Important Information

This page last updated and accepted by CMS January, 2010.

MedicareBlue Rx (PDP) is a Medicare-approved Part D sponsor. MedicareBlue PPO (Regional PPO) is a Medicare-approved regional PPO plan.

Coverage is available to residents of the service area or members of an employer or union group and separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.*

*Independent licensees of the Blue Cross and Blue Shield Association.