Request prior plan approval

These forms are intended for service requests requiring prior plan approval, pre-certification, or certification when being reimbursed through the member's benefits. These include Acute Inpatient Admissions, Elective Inpatient Admissions and PPA Code procedures or services, both outpatient and inpatient. Also included are medical plan drug requests and any quantity limit requests for these medications. View the prescription drug page for more details.

• Avalon Lab Services Fax Form (PDF)
• Facet Joint Denervation Fax Form (PDF)
• In-Network Benefit Review Request (PDF)
• Laparoscopic Radiofrequency Ablation (RFA) of Uterine Fibroids: Acessa™(PDF)
• Prostatic Urethral Lift Fax Form (PDF)
• Skilled Nursing Facility, Rehab and Long Term Acute Care Fax Back Form (PDF)
• Topical Negative Pressure Therapy for Wounds (PDF)
• Topical Negative Pressure Therapy for Wounds Extension (PDF)
• Fax form for all other Prior Review Services and Procedures (PDF)

For State Health Plan members, use the commercial fax forms.

• Adaptive Behavioral Treatment for Autism Spectrum Disorder/Applied Behavioral Analysis (ABA/ABT) (PDF)

• Behavioral Health Care Length of Stay Extension Authorization Request (PDF)

• Eating Disorder Inpatient or Residential Treatment Authorization Request (PDF)

• Electroconvulsive Therapy (ECT) Authorization Request (PDF)

• Inpatient Psychiatric Care Authorization Request (PDF)

• Residential Treatment for Behavioral Health Authorization Request Form (PDF)

• Residential Treatment for Substance Use Disorder Authorization Request (PDF)

• Transcranial Magnetic Stimulation Authorization Request Form (PDF)

The fax forms below are for services in January 1, 2020, and later, and only apply to Blue Medicare HMO and Blue Medicare PPO.

For other services and procedures:

By fax:

• Episodic Case Management (acute inpatient rehab, DME, home health, etc.): 336-659-2945
• Concurrent Review/Discharge Planning: 336-794-1555
• Pre-certification, including behavioral health services: 336-794-1556

By phone:

Blue Medicare Utilization Management: 888-296-9790 Monday – Friday, 8 a.m. - 5 p.m., Eastern time

• 2023 Prior Authorization Guidelines (PDF)
• 2022 Prior Authorization Guidelines (PDF)
• 2021 Prior Authorization Guidelines (PDF)
• 2020 Prior Authorization Guidelines (PDF)
• 2019 Prior Authorization Guidelines (PDF)

Some services and procedures received in a nonemergency situation on an outpatient basis require prior plan approval.

Behavioral health (mental health / substance use disorder) fax forms

• Electroconvulsive Therapy (ECT) (PDF)
• Inpatient Psychiatric Care (PDF)
• Transcranial Magnetic Stimulation (TMS) (PDF)

• Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO) PA Request Form (PDF)
• Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep Apnea PA Request Form (PDF)
• Bi-level Positive Airway Pressure (BIPAP) for Treatment of Breathing Related Sleep Disorders PA Request Form (PDF)
• Bi-Level Positive Airway Pressure with Backup Rate (BIPAP ST) for Treatment of Breathing Related Sleep Disorders PA Request Form (PDF)
• Continuous Positive Airway Pressure (CPAP) Rental or Purchase Prior Authorization (PA) Request Form (PDF)
• Durable Medical Equipment (DME) Repair or Replacement Prior Authorization (PA) Request Form (PDF)
• Hospital Bed PA Request Form (PDF)
• Knee Orthosis PA Request Form (PDF)
• Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO) PA Request Form (PDF)
• Negative Pressure Wound Therapy (NPWT) Pump Rental PA Request Form (PDF)
• Non-invasive Home Ventilator PA Request Form (PDF)
• Oxygen PA Request Form (PDF)
• Standard Wheelchair PA Request Form (PDF)

Behavioral health (mental health/substance use disorder) fax forms

The fax form below is for services in January 1, 2020 and later.

• Inpatient Psychiatric Care (PDF)

Certain durable medical equipment fax forms

• Ankle Foot Orthosis (AFO) or Knee Ankle Foot Orthosis (KAFO) Prior Authorization (PA) Request Form (PDF)

• Bi-level Positive Airway Pressure (BIPAP) for Treatment of Breathing Related Sleep Disorders Prior Authorization (PA) Request Form (PDF)

• Bi-Level Positive Airway Pressure (BiPAP) for Treatment of Obstructive Sleep Apnea Prior Authorization (PA) Request Form (PDF)

• Bi-Level Positive Airway Pressure with Backup Rate (BIPAP ST) for Treatment of Breathing Related Sleep Disorders Prior Authorization (PA) Request Form (PDF)

• Continuous Positive Airway Pressure (CPAP) Rental or Purchase Prior Authorization (PA) Request Form (PDF)

• Durable Medical Equipment (DME) Repair or Replacement Prior Authorization (PA) Request Form (PDF)

• Hospital Bed Prior Authorization (PA) Request Form (PDF)

• Knee Orthosis Prior Authorization (PA) Request Form (PDF)

• Lumbar Sacral Orthosis (LSO)/Thoracic Lumbar Sacral Orthosis (TLSO) Prior Authorization (PA) Request Form (PDF)

• Negative Pressure Wound Therapy (NPWT) Pump Rental Prior Authorization (PA) Request Form (PDF)

• Non-invasive Home Ventilator Prior Authorization (PA) Request Form (PDF)

• Oxygen Prior Authorization (PA) Request Form (PDF)

• Standard Wheelchair Prior Authorization (PA) Request Form (PDF)

Below are the essential forms that are required to be completed prior to rendering services such as general pre-certification forms, behavioral health treatment and refund requests.

• Behavioral Health Concurrent Review Fax Fom (PDF)
  Please complete for any concurrent review
• Behavioral Health Discharge Note (PDF)
  Form provides information when member will be discharged from behavioral health treatment
• Electroconvulsive Therapy Prior Authorization Request (PDF)
  ECT services require prior authorization and form must be submitted prior to rendering treatment
• General Precertification Request (PDF)
  Form can be used to request prior authorization for inpatient admissions
• Initial Note Review (PDF)
  Request for an initial case for behavioral health
• Mental Health Outpatient Treatment Report (PDF)
  Services require prior authorization and form must be completed prior to rendering treatment
• Neuropsychological Testing (PDF)
  Request for Authorization-services require prior authorization and form must be submitted prior to rendering treatment
• Overpayment Refund Notification Form (PDF)
  Please complete this form when refunding money and include all necessary documentation
• Psychological Testing Request for Authorization (PDF)
  Services require prior authorization and form must be completed prior to rendering treatment
• Recoupment Authorization Form (PDF)
  Please complete this form and mail with supporting documentation authorizing adjustments to be offset/recouped from future claims payments, do not enclose a check for the amount to be refunded when submitting this form.
• Transcranial Magnetic Stimulation (TMS) Request Form (PDF)
  Please complete this form in its entirety and submit for prior review when rendering TMS services.