Request Preauthorization

 

Certain services and procedures require preauthorization before they can be covered by your health insurance plan. Preauthorization ensures:

• The service or procedure is medically necessary and performed in the appropriate health care setting, so you get the right care at the right place at the right time.
• You and your health care provider can check if your benefit plan covers the service or procedure before you receive it, helping you avoid unexpected medical bills. 
• Special medical circumstances that may require review and follow-up are identified, aligning support you’ll need along your health journey.

What types of services and procedures require preauthorization?

Preauthorization requirements vary by benefit plan. Services and procedures that need preauthorization can include:

• Advanced diagnostic imaging
• All inpatient hospital admissions and some related procedures
• Certain prescription drugs 
• Genetic testing
• Hospice care
• Inpatient or outpatient surgical procedures
• Inpatient physical rehabilitation
• Inpatient residential treatment 
• Laboratory or radiology procedures 
• Long term acute care at an inpatient facility after receiving treatment in the hospital
• Organ and tissue transplants
• Skilled nursing care in the home
• Skilled nursing facility care
• Subsequent purchases of durable medical equipment (DME) or DME identified on the preauthorization list

Note: These are examples of services and procedures requiring preauthorization; it is not an all-inclusive list. Services and procedures requiring preauthorization are subject to change.

Standard X-rays and radiology services performed with emergency room services and inpatient hospitalization are not included in this requirement. 

How do I check if a service or procedure requires preauthorization?

Your health care provider will typically check on your behalf if a service or procedure requires preauthorization. You can check online as well by:

1. Visiting Med Policy Blue, our online medical policy resource.
2. Searching by key word, such as the name of a service or procedure or the procedure code, which you can get from your health care provider. 

Or

1. Calling the Member Services phone number on the back of your member ID card. 

As the member, you are responsible for ensuring a preauthorization request is sent in and approved by Blue Cross and Blue Shield of Nebraska (BCBSNE) before receiving a service or procedure requiring preauthorization. If a service or procedure is not preauthorized or the preauthorization is denied, the claim may be denied, and you may be responsible for the payment of the charges.

How do I receive preauthorization?

Your health care provider will submit a preauthorization request to BCBSNE on your behalf. You are responsible for checking with your provider that preauthorization is obtained when required for a service or procedure before receiving care. If you receive care requiring a preauthorization and did not obtain approval first, the claims for those services or procedures may be denied and may be considered your liability. Please review liability by provider type:

• For in-network providers in Nebraska: The provider is liable for costs if preauthorization is not obtained before care is received. 
• For in-network providers outside of Nebraska: You, as the member, may be liable for costs if preauthorization is not obtained before care is received. 
• Out-of-network providers in and outside of Nebraska: You, as the member, may be liable for costs if preauthorization is not obtained before care is received. 

Please be aware that, at times, we may deny a preauthorization request deemed not medically necessary and/or investigational, per BCBSNE policies. If a service or procedure is provided, but not approved, you may be responsible for the charges associated with the service or procedure.

What resources can I share with my health care provider to help them complete preauthorization on my behalf?

Please direct your health care provider to BCBSNE’s preauthorization page for providers for additional information.