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Precertification and Prior Authorization

Prior Authorization or Precertification:  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).

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;
  • in accordance with the current generally accepted standards of medical practice in the United States based on credible scientific evidence;
  • 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 Precertification and Prior Authorization?

Precertification and prior authorization 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, precertification and prior authorization 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 precertification/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, prior authorization is required.

Precertification/Prior Authorization Requirements

Precertification

Precertification 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, for obstetrical care or occurs outside the 50 United States.

How to Submit a Request or View Status of Existing Request:
Visit the secure pre-certification section.

Sign-in to Availity

Members of some group health plans may have terms of coverage or benefits that differ from the information presented here.  The following information describes the general policies of BCBSKS and is provided for reference only.  This information is NOT to be relied upon as prior authorization or precertification for health care services and is NOT a guarantee of payment.  To verify coverage or benefits or determine precertification or authorization requirements for a particular member, call 800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.

Precertification/Authorization information for out-of-area members

To view the out-of-area Blue Plan's general precertification/authorization information, enter the first three letters of the member's identification number on the Blue Cross Blue Shield ID card, and click "GO."

Type of information being requested

Please select one at a time




 

If you experience difficulties or need additional information, please contact 800-676-BLUE.

Prior Authorization

Please review criteria and fax or email a completed prior authorization form

All other drugs may be prior authorized electronically by completing the prior authorization form through CoverMyMeds. If you need medical policies for these drugs, you will find a list below the CoverMyMeds form.

Prior Authorization Medication List

Many of our pharmacy medical policies are now being maintained through our pharmacy benefit manager, Prime Therapeutics.

To find pharmacy medical policies specific to a medication list, use the links below.

Policies may be temporarily housed here prior to being posted to the myprime.com website.