For Providers

Prior Authorization

Services for Which Prior Authorization is Recommended

(Effective 1/18/2008)

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

Services Subject to Post-Service Review (after a claim is received)

Deep Brain Stimulation
Drugs, including but not limited to:
- Growth hormone
- Intravenous immune globulin (IVIG)
Durable medical equipment exceeding $1000
Prosthetics exceeding $5000
Reconstructive procedures and potentially cosmetic procedures, such as:
- Blepharoplasty
- Panniculectomy
- Rhinoplasty
- Scar excision/revision
- Reduction mammoplasty, mastoplexy
Surgical Treatment of Sleep Apnea
Vagus Nerve Stimulation

NOTE:

MedicareBlue PPO has changed the services for which prior authorization is recommended (effective 1/18/08).

Some services were removed from the recommended prior authorization list
Some services with specific coverage criteria will be reviewed after the claim is submitted to determine if criteria are being met
Increasing prices for Durable Medical Equipment (DME) were taken into account.
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/TDD 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.

May 16, 2008

Important Information

This page last updated and accepted by CMS January 2008.

MedicareBlue PPO and MedicareBlue Rx coverage is provided by only one of the following plans, depending on the state in which the policy is issued: 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.

R5566_122007_B07 RE

S5743_122007_B08 RE