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Check First! Medical and Pharmacy Services that Need Prior Authorization

As part of your Florida Blue health coverage, we provide services to help you save money by avoiding unnecessary costs. When you and your doctor are making decisions about your health care and how your benefits will work, we can help.

Ahead of some services, we ask your doctor to consult with our medical and pharmacy teams to discuss and agree on the course of treatment. This helps be sure you’re getting the right care and to know that your procedure or medication will be covered. Be sure your doctor gets the following services approved in advance (also called prior authorization). You may be responsible to pay for the services that are not approved.

With a Prior Authorization:

  • Service is covered
  • You pay your cost-share

Without a Prior Authorization:

  • Service may not be covered
  • You pay the entire cost or a benefit penalty may be applied

This list is subject to change. Call us at the number on your member ID card if you have any questions or want to confirm the services listed.

Services that require Prior Authorization

What

  • Radiological services such as CT, CTAs, MRIs/MRAs, PET scans and nuclear medicine and cardiovascular system procedures (myocardial imaging, myocardial infusion studies and cardiac blood pool imaging).

Where and When

  • Before these services are provided in an Outpatient Hospital or Office location.
  • Prior Authorization is not required for advanced imaging services in an emergency room, observation stay, or during an inpatient hospital admission.

Why

  • Helps ensure the tests are done in the proper order, eliminate unnecessary tests and decrease the risk of overexposure to radiation. Studies have shown that overexposure to radiation can have negative affects on your health.
  • Helps lower your overall medical costs and maximizes your coverage within your benefits.

How

  • Your doctor must contact Florida Blue's imaging coordinator, Magellan Healthcare National Imaging Associates (NIA), at 1-866- 326-6302 or via RadMD.com.
  • You can also check the status of your authorization by contacting the phone number on the back of your ID card.

Next Steps

Please refer to your policy for a complete description of benefits and exclusions.

  • Florida Blue or its delegate will review the request and an approval or denial letter will be mailed to you. Please keep this letter for your records.
  • With an approval, service is covered at your cost share amount and approved location.
  • If there is a denial or no approval, the service is not covered and you may be responsible for the entire cost or a benefit penalty may be applied.
  • If the request is not approved, you can talk to your doctor about treatment options. You also have the right to appeal the decision. To download the appeal form, click on the following links (these can be found on the Member Forms page):

What

  • Oncology drugs and medical injectables. For a list of these drugs, please click here or contact the Customer Service number on your member ID card.

Where and When

  • Prior Authorization is required before these drugs are administered in these locations: a doctor's office, at home, outpatient hospital, ambulatory surgical center or a health clinic.
  • Prior Authorization is not required in an emergency room, inpatient hospital or an urgent care center.

Why

  • Helps ensure that you will receive cost-effective quality treatment.
  • Helps lower your overall medical costs and maximizes your coverage within your benefits.

How

  • Your doctor must contact Florida Blue at 1-877-719-2583 or its delegate at (800) 424-4947 at MagellanRx Management.
  • You can also check the status of your authorization by contacting the phone number on the back of your ID card.

Next Steps

Please refer to your policy for a complete description of benefits and exclusions.

  • Florida Blue or its delegate will review the request and an approval or denial letter will be mailed to you. Please keep this letter for your records.
  • With an approval, service is covered at your cost share amount and approved location.
  • If there is a denial or no approval, the service is not covered and you may be responsible for the entire cost or a benefit penalty may be applied.
  • If the request is not approved, you can talk to your doctor about treatment options. You also have the right to appeal the decision. To download the appeal form, click on the following links (these can be found on the Member Forms page):

What

  • Cardiology services including echocardiography, diagnostic coronary angiography, Percutaneous Coronary Intervention (PCI) and arterial ultrasound.

Where and When

  • Before these services are provided in an outpatient hospital or office location.
  • Preapproval review is not required for cardiology services in an emergency room, observation stay or during an inpatient hospital admission.

Why

  • Helps ensure that clinically appropriate quality of care is provided. Helps lower your overall medical costs and maximizes your coverage within your benefits.
  • Helps lower your overall medical costs and maximizes your coverage within your benefits.

How

  • Your doctor must contact Florida Blue via Availity.com
  • You can check the status of your authorization by calling the customer service number on your ID card.

Next Steps

Please refer to your policy for a complete description of benefits and exclusions.

  • Florida Blue will review the request and an approval or denial letter will be mailed to you. Please keep this letter for your records.
  • With an approval, service is covered at your cost share amount and approved location.
  • If there is a denial or no approval, the service is not covered and you may be responsible for the entire cost or a benefit penalty may be applied.
  • If the request is not approved, you can talk to your doctor about treatment options. You also have the right to appeal the decision. To download the appeal form, click on the following links (these can be found on the Member Forms page):

What

  • Sleep studies performed to diagnose certain sleep disorders (snoring, apneas, hypopneas, etc.).

Where and When

  • Once a lab sleep test or home sleep test is ordered by a qualified physician, prior authorization must by obtained for a location of service.
  • As a general rule prior authorization is not required for services in an emergency setting.

Why

  • The same quality of testing can be performed in the comfort of your home if deemed appropriate by your physician. In many cases home tests are just as effective in a lab setting.
  • Helps lower your overall medical costs and maximizes your coverage within your benefits.

How

  • Your doctor must contact SMS at 1-855-243-3326.
  • You can also check the status of your authorization by contacting the phone number on the back of your ID card.

Next Steps

Please refer to your policy for a complete description of benefits and exclusions.

  • Florida Blue or its delegate will review the request and an approval or denial letter will be mailed to you. Please keep this letter for your records.
  • With an approval, service is covered at your cost share amount and approved location.
  • If there is a denial or no approval, the service is not covered and you may be responsible for the entire cost or a benefit penalty may be applied.
  • If the request is not approved, you can talk to your doctor about treatment options. You also have the right to appeal the decision. To download the appeal form, click on the following links (these can be found on the Member Forms page):

What

  • Hip surgeries including, revision/conversion hip arthroplasty; total hip arthroplasty/resurfacing; femoroacetabular impingement (FAI), which includes CAM/pincher & labral repair; other hip surgeries, including synovectomy, loose body removal, debridement, diagnostic and extra-articular hip arthroscopy.

Where and When

  • Before these services are provided in an outpatient hospital, inpatient hospital admission or office location.
  • Preapproval is not required for hip & knee surgeries received in an emergency room or observation stay.

Why

  • Helps ensure that clinically appropriate quality of care is provided.

How

  • Your doctor must contact Florida Blue via Availity.com
  • You can also check the status of your authorization by contacting the phone number on the back of your ID card.You can check the status of your authorization by calling the customer service number on your ID card.

Next Steps

Please refer to your policy for a complete description of benefits and exclusions.

  • Florida Blue or its delegate will review the request and an approval or denial letter will be mailed to you. Please keep this letter for your records.
  • With an approval, service is covered at your cost share amount and approved location.
  • If there is a denial or no approval, the service is not covered and you may be responsible for the entire cost or a benefit penalty may be applied.
  • If the request is not approved, you can talk to your doctor about treatment options. You also have the right to appeal the decision. To download the appeal form, click on the following links (these can be found on the Member Forms page):

What

  • Spine care includes health services for many cervical (neck-related) or lumbar (back-related) treatments. Treatments in the program include:
    • Injections or shots that are not received in the emergency room or hospital setting, such as for blocking lower back pain and deadening nerves.
    • Surgeries you receive in any setting (inpatient or outpatient) on your neck or back to correct discs or improve lower back pain.

Where and When

  • Before these services are provided at an inpatient, outpatient, or office location, such as:
  • Interventional spine management services at any location, except inpatient at a hospital:
    • Spinal epidural injections
    • Paravertebral facet joint injections or blocks
    • Paravertebral facet joint denervation [radio frequency (RF) neurolysis]
  • Spine surgeries performed at any location:

    Note: A prior authorization is not required for the health services listed above in an emergency care situation.

    • Lumbar microdiscectomy
    • Lumbar decompression (laminotomy, laminectomy, facetectomy and foraminotomy)
    • Lumbar spine fusion (arthrodesis), with or without decompression – single and multiple levels
    • Cervical anterior decompression, with fusion – single and multiple levels
    • Cervical posterior decompression, with fusion – single and multiple levels
    • Cervical posterior decompression, without fusion
    • Cervical artificial disc replacement
    • Cervical anterior decompression, without fusion

Why

  • Helps ensure that clinically appropriate quality of care is provided.
  • Helps lower your overall medical costs and maximizes your coverage within your benefits.

How

  • Your doctor must contact Florida Blue's imaging coordinator, National Imaging Associates (NIA), at 1-866- 326-6302 or via RadMD.com.
  • You can also check the status of your authorization or pre-approval by calling the Customer Service phone number on your member ID card.

Next Steps

  • Before these services are provided at an inpatient, outpatient, or office location, such as:
  • Interventional spine management services at any location, except inpatient at a hospital:
    • Spinal epidural injections
    • Paravertebral facet joint injections or blocks
    • Paravertebral facet joint denervation [radio frequency (RF) neurolysis]
  • Spine surgeries performed at any location:

    Note: A prior authorization is not required for the health services listed above in an emergency care situation.

    • Lumbar microdiscectomy
    • Lumbar decompression (laminotomy, laminectomy, facetectomy and foraminotomy)
    • Lumbar spine fusion (arthrodesis), with or without decompression – single and multiple levels
    • Cervical anterior decompression, with fusion – single and multiple levels
    • Cervical posterior decompression, with fusion – single and multiple levels
    • Cervical posterior decompression, without fusion
    • Cervical artificial disc replacement
    • Cervical anterior decompression, without fusion
    • Helps ensure that clinically appropriate quality of care is provided.
    • Helps lower your overall medical costs and maximizes your coverage within your benefits.
    • Your doctor must contact Florida Blue's imaging coordinator, National Imaging Associates (NIA), at 1-866- 326-6302 or via RadMD.com.
    • You can also check the status of your authorization or pre-approval by calling the Customer Service phone number on your member ID card.
    • Florida Blue or its delegate will review the request and an approval or denial letter will be mailed to you. Please keep this letter for your records.
    • With an approval, service is covered at your cost share amount and approved location.
    • Without an approval:

      Please refer to your policy for a complete description of benefits and exclusions.

      • the service will not be covered and you will pay the full cost if the service does not meet the definition of Medical Necessity as defined in your health plan contract/policy.
      • for spine surgeries, you will pay your plan cost share amount (i.e., coinsurance and deductible) plus 20% of the total Allowed Amount of the claim, if you receive a Medically Necessary service as defined in your contract/policy without a prior authorization.
      • You also have the right to appeal the decision. To download the appeal form, click on the following links (these can be found on the Member Forms page):

What

  • Radiation oncology therapy treatments for all cancer types, such as Intensity Modulated Radiotherapy, 3D Conformal, Proton Beam Therapy, Stereotactic Body Radiation , Stereotactic Radiosurgery, Brachytherapy and other associated services.

Where and When

  • Before these services are provided at an outpatient location, except in cases of an emergency.

Why

  • Helps ensure that clinically appropriate quality of care is provided.
  • Helps lower your overall medical costs and maximizes your coverage within your benefits.

How

  • Your doctor must contact Florida Blue via Availity.com.
  • You can check the status of your authorization by calling the customer service number on your ID card.

Next Steps

  • Florida Blue will review the request and an approval or denial letter will be mailed to you. Please keep this letter for your records.
  • With an approval, service is covered at your cost share amount and approved location.
  • If there is a denial or no approval, the service is not covered and you may be responsible for the entire cost or a benefit penalty may be applied.
  • If the request is not approved, you can talk to your doctor about treatment options. You also have the right to appeal the decision. To download the appeal form, click on the following links (these can be found on the Member Forms page):

Know Before You Go: Steps for getting a Prior Authorization

1. Inform your Doctor

Let your doctor know that you may need prior approval for certain medical services. When your doctor tells you that you need one of the services listed above, he'll contact us to request the authorization.

Be sure you have the approval before you schedule your appointment for the medical service.

2. We'll Review your Request

After your doctor has submitted the request, we'll review it and work with them to be sure you get quality care and the greatest value for your benefits. An authorization review can take between 2 to 3 business days to complete.

3. You’ll Receive a Notice

Florida Blue will mail you a letter confirming that your medical service have been approved or denied. Keep the letter for future reference. If the request has not been approved, the letter will tell you the steps to appeal the decision. We'll also let your doctor know the decision, so please contact them to discuss other medical service options.

You can check the status of the request by calling the number on the back of your member ID card.

We are here to help you! If you have any questions or need further assistance after reading these steps, please call us at the number on the back of your member ID card. If your provider has any questions, they should call us at 1-800-727-2227.

Please note: Services, procedures or medications that may not require prior approval may be subject to medial review and medical coverage guidelines. If you have a BlueCare health plan, other services that require your participating provider to obtain an approval can include: behavioral health services, hospitalization, rehabilitation services, home care, select DME and cardiac nuclear medicine studies, etc. Please refer to your contract or benefit booklet or call us at the number on the back of your member ID card for more details.

Prior Authorization FAQs

Prior authorization is a medical review required for certain services or supplies before they are obtained to determine if they are eligible for payment by your health plan.

You are solely responsible for getting any required authorization before services are rendered, regardless of whether you go to an in- or out-of-network health care provider. An in-network health care provider will request a prior authorization on your behalf. However, out-of-network providers are not contracted with us and have not agreed to accept this responsibility. We encourage you to verify that a Prior Authorization has been approved BEFORE you receive services or supplies that require a Prior Authorization.

The approval time can vary based on the medical service you need. After a request has been submitted, feel free to call us the Customer Service number on your member ID card to check the status.

Call Customer Service at the number on the back of your member ID card.

No, Prior Authorization is not required in an emergency situation.

The service or supply may not be covered and you may be responsible for the entire cost. Please see your benefit booklet or contract for details, or call the Customer Service number on your member ID card.

Prior Authorization requirements vary by plan. For details, please refer to your benefit booklet or contract or call the Customer Service number on your member ID card for details.

Your cost-share is the amount you are responsible for paying for covered services as specified in your Schedule of Benefits, benefit book or contract (i.e., copay, coinsurance or deductible).

Yes. The location may be a factor. The price and quality can vary depending on where you go. Florida Blue may authorize a different location that provides quality and cost-effective care that can also help lower your out-of-pocket costs. Please see your benefit booklet or contract for details, or call the Customer Service number on your member ID card.

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