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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.

Commercial forms

Behavioral Health (mental health/substance use disorders) fax forms

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

Blue Medicare forms

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: 336-794-1556
  • Pre-certification for Behavioral Health Services: 336-794-1557

By phone:

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

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

Certain durable medical equipment fax forms

Healthy Blue + Medicare (HMO-DSNP) forms

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.

Contact Utilization Management

Monday through Friday, 8 a.m. to 5 p.m. ET