We may require prior authorization reviews to confirm:

• Member eligibility
• Benefit coverage
• Compliance with Commercial and Blue Medicare^℠ medical policies regarding medical necessity
• Appropriateness of setting
• Requirements for use of in-network and out-of-network facilities and professionals
• Identification of comorbidities and other problems requiring specific discharge needs
• Identification of circumstances that may indicate:
  • a referral to concurrent review, discharge services, or case management
  • a referral to a second opinion, continuity of care, or case management
  • a referral to chronic case management