Prior Authorization

Some services may require Prior Authorization from Blue Cross Community Health Plans^SM (BCCHP). Prior Authorization means getting an OK from BCCHP before services are covered. You do not need to contact us for a Prior Authorization. You can work with your doctor to submit a Prior Authorization.

BCCHP won’t pay for services from a provider that isn’t part of the BCCHP network if Prior Authorization is not given. You can work with an out-of-network provider to receive Prior Authorization before getting services.

Some services that do not need a Prior Authorization are:

• Primary care
• In-network specialist
• Family planning
• WHCP services (you must choose doctors in the network)
• Emergency care

Review the Certificate of Coverage starting on page 3. It has a full list of covered services and if a Prior Authorization is needed. 

Your doctors will use other tools to check Prior Authorization needs. These tools used by PCPs (or specialists) include medical codes. Our doctors and staff make decisions about your care based on need and benefits. They use what is called clinical criteria to make sure you get the health care you need. Medical policies are also used to guide care decisions. Medical Policies are based on scientific and medical research.

See Prior Authorization tools, clinical review criteria and BCCHP Medical Policies. These are used by your doctor to make a decision.

BCCHP has strict rules about how decisions are made about your care. Our doctors and staff make decisions about your care based only on need and benefits. There are no rewards to deny or promote care. BCCHP does not encourage doctors to give less care than you need. Doctors are not paid to deny care.

You can talk to a BCCHP staff member about our utilization management (UM) process. UM means we look at medical records, claims, and prior authorization requests. This is to make sure services are medically necessary. We also check that services are provided in the right setting and that services are consistent with the condition reported. If you want to know more about this process or how decisions are made about your care, contact Member Services at 1-877-860-2837 (TTY/TDD: 711).