Prior authorization info for members
Medical providers submit prior authorizations for patients. For more info, call customer service at 800-432-3990 or review the general info below.
Providers
Prior authorization and pre-certification
Prior authorization or pre-certification: the process of determining whether certain services, supplies or prescription drugs are medically necessary based on criteria established by Blue Cross and Blue Shield of Kansas (BCBSKS).
Prescription drugs
Prescription drugs requiring prior authorization
The following list contains medications that require prior authorization and the correct pathway for prior authorization submission should you need assistance.
Prescription drugs requiring prior authorization through BCBSKS
The following instances require internal review by BCBSKS. To initiate a request, review criteria and fax or email a completed Prior Authorization Form (pdf).
- ACA Prevention Copay Waiver Criteria - Individual Marketplace, Commercial
- Search for this policy at: Medical Policies
- Compounded Prescriptions Greater Than $100 Form (pdf)
- Human Growth Hormone
- Search for this policy at: Medical Policies
- Site of Care
- Very High Cost Drugs and Therapies
Submit prior authorization for medications reviewed by Prime Therapeutics
Prior authorization policies for prescription drugs
To find pharmacy policies specific to a medication, use the links below.
Prescription drug policies*
BCBSKS BlueCare/EPO Prior Authorization (Prime)
BCBSKS ResultsRx Prior Authorization (Prime)
BCBSKS Select Prior Authorization (Prime)
BCBSKS ResultsRx Prior Authorization (Prime)
BCBSKS Select Prior Authorization (Prime)
* Policies may be temporarily housed here prior to being posted to myprime.com.
Medical Pharmacy Solutions program policies
Medical policies for medications that are part of the Medical Pharmacy Solutions program can be found at Blue Cross and Blue Shield of Kansas Medical Pharmacy Policies (GatewayPA).
Medical services
Medical services requiring prior authorization
- All home health and hospice services (for assistance call: 800-782-4437)
- Applied Behavior Analysis (ABA) therapy services (for assistance call: 877-563-9347)
- Transplants with the exception of cornea and kidney (for assistance call: 800-432-0272)
- Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
- Search for this policy at: Medical Policies
- To request prior authorization, review policy and fax or email a completed Prior Authorization Form (PDF).
Pre-certification requirements
Pre-certification is the process of performing a prior authorization review as required by BCBSKS for inpatient admissions unless the admission is for a medical emergency, a life-threatening condition, obstetrical care or occurs outside the 50 United States.
Pre-certification is required for:
- All inpatient medical stays (for assistance call: 800-782-4437)
- All inpatient mental health stays (for assistance call: 800-952-5906)
Submit a pre-certification request or check status
To submit a new request or check the status of an existing request, see the secure pre-certification section within Availity.
Pre-certification / preauthorization
Out-of-area members information
To view the out-of-area Blue Plan's general pre-certification/preauthorization information, enter the first three letters of the member's identification number on the Blue Cross Blue Shield ID card, and select "GO."
If you experience difficulties or need additional information, please contact 800-676-2583 (BLUE).
Prior authorization metrics report
To comply with the CMS Interoperability and Prior Authorization final rule Blue Cross and Blue Shield of Kansas is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes and enables providers to evaluate payer performance.
Frequently asked questions
What is the definition of medically necessary?
Medically necessary is defined as:
- Performed, referred, and/or prescribed by a duly licensed provider;
- Provided in the most appropriate setting and consistent with the diagnosis and treatment of the Insured's condition;
- Not primarily for the convenience of the patient, physician or other health care provider;
- Not more costly than an alternative service or supply or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the Insured's illness, injury or disease.
What is the purpose of prior authorization and pre-certification?
Prior authorization and pre-certification serve as a checks and balances system. They help ensure the proper use of insurance benefits, and it helps health insurance companies control the risk of fraud and inappropriate use. Ultimately, prior authorization and pre-certification help keep the cost of health care premiums affordable for everyone.
What are other commonly-used terms defined in the member contract?
Pre-service claim
A request for a claim's decision when prior authorization of the services is required by BCBSKS. These are defined in the member contract and on this website under pre-certification/prior authorization.
Pre-service request
A request for advance information for possible coverage of items or services or advance approval of covered items or services that do not require prior authorization.
- Pre-service requests are a courtesy review performed by BCBSKS.
- Some examples may include requests for services, supplies, or prescription drugs that have a medical policy, are high-cost, could be deemed experimental/investigation or non-covered based on the member's contract to determine coverage.
- If the service is being performed inpatient, pre-certification is required.
Disclaimers
Members of some group health plans may have terms of coverage or benefits that differ from the information presented here. The information on this page describes the general policies of BCBSKS and is provided for reference only. This information is NOT to be relied upon as prior authorization or pre-certification for health care services and is NOT a guarantee of payment. To verify coverage or benefits or determine pre-certification or authorization requirements for a particular member, call 800-676-2583 (BLUE) or send an electronic inquiry through your established connection with your local Blue Plan.