Prior Authorization

Some services need approval from your health plan before you get treated. This approval is called prior authorization. Your doctor should know which services need approval and can help with the details.

Who is responsible for getting the prior authorization?

Your PCP will handle the prior authorization process.

How do I know if I need a prior authorization?

Your Summary of Benefits has information about which services require prior authorization. Your PCP will handle the prior authorization process.

View your plan's Summary of Benefits.

How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM Make Decisions for Prior Authorizations?

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.

Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision.

Coverage Decisions

Blue Cross Community MMAI 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. Your plan does not encourage doctors to give less care than you need. Doctors are not paid to deny care.

If you want to know more about the utilization management process or how decisions are made about your care, Contact Us.