Preauthorization is a program in which doctors and nurses collaborate to evaluate and monitor specific health care services.
The general purpose of the preauthorization program is to make sure members receive:
- Medically appropriate treatment to meet individual needs
- Care by participating providers delivered in an efficient and effective manner
- Maximum available benefits, resources and coverage
The Capital BlueCross Pre-Admission Call Program and Discharge Outreach Program are components of preauthorization.
To learn more about the criteria used in making a utilization management decision, please call 1.800.471.2242.
Helping you make the most of your benefits
All inpatient admissions, selected surgical procedures and certain outpatient procedures require approval before they are performed. When care is performed or coordinated by your Primary Care Physician (for those in the HMO and POS Plans), the network provider is responsible for obtaining preauthorization for you.
If you self-refer for care, or use an out-of-network provider, it is your responsibility to obtain preauthorization for those services requiring it. To obtain preauthorization, call 1.800.471.2242 or ask your provider to call. (Note: For HMO members, preauthorization must be obtained by the provider. Members may not self-refer for care requiring preauthorization.)
View the PDFs* below to review the services that require preauthorization for your coverage type:
- Capital BlueCross Products PPO, Comprehensive, POS
- Capital BlueCross Traditional
- Keystone Health Plan Central HMO
Note: Investigational/experimental and cosmetic procedures are not eligible for coverage under most Plans. To determine if a service is investigational/experimental or cosmetic, please contact the Preauthorization Department.
To obtain preauthorization, contact the Clinical Management Department by calling 1.800.471.2242, Monday through Friday, 8 a.m.- 5 p.m. EST.