Bcbs federal prior authorization form pdf

2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
How to request precertification for an admission or get prior approval for Other services

How to request precertification for an admission or get prior approval for Other services

• Enrollee’s name and Plan identification number;
  
• Patient’s name, birth date, and phone number;
  
• Reason for inpatient admission, proposed treatment, or surgery;
  
• Name and phone number of admitting physician;
  
• Name of hospital or facility;
  
• Number of days requested for hospital stay;
  
• Any other information we may request related to the services to be provided; and
  
• If the admission is to a residential treatment center (RTC), a preliminary treatment and discharge plan agreed to by the member, provider and case manager at the Local Plan, and the RTC.

Note: If we approve the request for prior approval or precertification, you will be provided with a notice that identifies the approved services and the authorization period. You must contact us with a request for a new approval five (5) business days prior to a change to the approved original request, and for requests for an extension beyond the approved authorization period in the notice you received. We will advise you of the information needed to review the request for change and/or extension.