Prior Authorization

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File claims, get prior authorizations, check eligibility and benefits and more.

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Always check benefits through the voice response unit or My Insurance ManagerSM to determine if prior authorization is required.

Healthy Blue requires prior authorization for certain procedures and durable medical equipment. This process allows us to check ahead of time whether services meet criteria for coverage by a member’s health plan.

To search for authorization by code, use the Prior Authorization Lookup Tool below.

In many cases, approval is instant. When it’s not, we’ll review your request, considering:

  • Our medical policies.
  • Recognized clinical guidelines.
  • The terms of the member’s benefit plan.

Some requests may require additional documentation.

How to Request Prior Authorization

Medical Services

When you request prior authorization from us, we want the process to be fast, easy and accurate. We offer these convenient options:

  • Call Provider Service at 866-757-8286.
  • Medical Forms Resource Center (MFRC) — This online tool makes it easy to submit prior authorization requests for certain services. The tool guides you through all the forms you need so you can avoid follow-up calls for additional information.
  • My Insurance Manager — You also can submit prior authorization using the same online self-service provider tool you can use to check eligibility, manage claims and more. Refer to the available guide for assistance.

Behavioral Health Services

  • Call 800-868-1032.
  • Fax 803-870-6506. 
  • Forms Resource Center — This online tool makes it easy for behavioral health clinicians to submit behavioral health prior authorization requests. The tool guides you through all the forms you need so you can avoid follow-up calls for additional information.
  • My Insurance Manager — You also can submit prior authorization using the same online self-service provider tool you can use to check eligibility, manage claims and more. Refer to the available guide for assistance.

Special Vendors

Evolent

Evolent is an independent company that manages the prior authorizations for radiology and high-tech imaging services on behalf of BlueChoice HealthPlan.

To request a prior authorization, you can:

Avalon Healthcare Solutions

Avalon is an independent company that manages the prior authorizations for laboratory services on behalf of BlueChoice HealthPlan.

Review the current Avalon list to see which codes require authorization.

To request a prior authorization, you can:

CarelonRx

CarelonRx is an independent company that manages the prior authorizations for certain medications on behalf of BlueChoice HealthPlan. 

To request a prior authorization, you can:

Retail

Home Delivery/Mail Order

Medical Injectables

Specialty Pharmacy

Prior Authorization Lookup Tool

Please verify benefit coverage prior to rendering services. Inpatient services and nonparticipating providers always require prior authorization (PA).

Please note:

  • Enter one CPT code at a time into the search.
  • This tool is for outpatient services only.
  • Inpatient services and nonparticipating providers always require PA.
  • This tool does not reflect benefits coverage nor does it include an exhaustive list of all noncovered services (that is, experimental procedures, cosmetic surgery, etc.). Refer to your provider manual for coverage/limitations.
  • For specialty pharmacy codes, visit the Pharmacy page and click on the "medical specialty drug list".
  • These codes are valid as of 8/1/2024.