Out-of-Area (BCBS Participating Provider) and Out-of-Network provider resources.
Out-of-network providers must login to submit the following forms electronically, or download, print, and fax to the number at the top of the respective form. If you do not already have one, you can register for a secure account in a few simple steps.
In-network providers should log in and use Availity Essentials.
Preauthorization request forms
Log in to submit electronically:
- Inpatient elective
- Peer to peer request
- Prior authorization modification and date extension request form – For all authorizations requesting future start date, updating diagnosis codes, changing the servicing, or rendering provider. Note: A new authorization form is required to add an additional visit or unit.
Fax to submit:
- Continuity care form
- Home health skilled nursing and/or therapy visit treatment
- Hospice control
- Inpatient elective admission - Non-urgent/emergent inpatient admissions.
- Letter of medical necessity - For all services that don’t have an otherwise explicitly listed form (e.g., DME, medical injectable prescriptions, outpatient surgery, genetic testing, etc.).
- Transplant request
Preauthorization specialty injectable forms (non-Medicare plans)
Fax to submit:
- Botulinum toxin preauthorization request
- Denosumab oncology (Xgeva®) and osteoporosis (Prolia®) preauthorization request
- Filgrastim preauthorization request
- Infliximabs preauthorization request
- Medical injectable drugs (non-drug specific) preauthorization request
- Ocrevus™ preauthorization request
- Pegfilgrastim preauthorization request
- Tysabri® preauthorization request
- Xolair® preauthorization request
For services authorized via our musculoskeletal services provider
If the CPT code is listed on the single source preauthorization list and indicates authorization via our musculoskeletal services provider, the following will apply.
Musculoskeletal services post service review process
Please follow the process below for post service surgical reviews:
Step 1
- Provider has received an authorization for requested CPT code(s).
- Following the procedure, the CPT code has changed due to performed surgical procedure:
- CPT code was added to the approved code or instead of the approved code(s).
- Operative note is required for verification of the additional procedure code(s).
Step 2
Complete the post-service claim review form.
- Fill in each section, especially the box indicating the update reason.
- Example: Approval was for CPT 29880 and during surgery, CPT code 29881 was performed.
Step 3
Fax the following information to our musculoskeletal services provider at 717.412.1001.
- Cover sheet with provider information, including contact name and phone number.
- Completed post-service claim review form.
- Operative note: Please make sure the member’s name is listed.
Step 4
Our musculoskeletal services provider will review the faxed information and make a determination within 7-10 business days.
- Our musculoskeletal services provider will notify the provider of the post service determination.
- Our musculoskeletal services provider will notify us of the determination.
- We will verify our records and perform any adjustments, if applicable.
Exclusions
If our musculoskeletal services provider denied the entire surgical request and the procedure was performed, it does not constitute a post service review.
- Provider can appeal the denied determination.
Behavioral health and applied behavior analysis authorization request forms
Log in to submit electronically:
- Applied behavior analysis approval request
- Behavioral health inpatient authorization request
- Behavioral health outpatient authorization request