Services Requiring Prior Authorization (June 2015)
Services requiring prior authorization (PA) for Healthy Blue members enrolled in the Healthy Connections program can be found by viewing the PA grid on our website. This list may not be all-inclusive; the last date this list was updated can be found at the top of the grid.
Providers are responsible for verifying eligibility and benefits before providing services to Healthy Blue members. Except for an emergency, failure to obtain PA for the services listed may result in a denial for reimbursement.
Note: Referral to an out-of-network provider and/or facility requires prior authorization for all services.
Requesting Prior Authorization
To request PA, report a medical admission or ask questions regarding PA, please contact our Utilization Management department at:
- Prior Authorization Forms
General Prior Authorization Forms
Forms for Specific Procedures/Items
- Universal 17P/Makena Authorization Form*
- Incontinence Certification
- Universal Medication Prior Authorization Form*
Please contact the Utilization Management Intake department for any questions on prior authorization at 1-866-902-1689 or fax 1-800-823-5520.
* These links lead to a third-party site. That organization is solely responsible for the contents and privacy policies on its site.
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