Commercial/FEP Procedures/Services: Individual QHP ...

1 Prior Authorization Request (Please do not use for Pharmacy or Behavioral Health). Submission of this information by fax or phone does not constitute authorization of services. Blue Cross of Idaho's Healthcare Operations department will notify you of its decision by fax, phone or via the portal at o For services that require authorization please see our Prior Authorization Requirements Checklists. Please fax this completed form, along with the medical records documenting the clinical indications or medical necessity to the appropriate fax number listed below. For routine requests, please allow 10 business days for processing. Commercial/FEP procedures /Services: Fax 208-331-7344 Individual QHP procedures /Services: Fax 208-286-3583. Inpatient Notification: Fax 208-331-7326 Medicare Advantage procedures /Services: Fax 208-395-8204.

2 Medicare Organizational Determination: (Services previously rendered with an ABN-see MA PAP 108) Fax 208-395-8204. IF DELAYING SERVICE COULD SERIOUSLY JEOPARDIZE THE MEMBER'S LIFE, HEALTH OR ABILITY TO REGAIN MAXIUMUM. FUNCTION PLEASE HAVE MEDICAL PROVIDER SIGN AND DATE. This does not apply to scheduling issues. I, Dr. _____ attest that the request for expedited prior authorization meets the criteria listed in PAP241, is documented and supported in the medical records. Expedited Reason:_____ Physician Signature:_____Date:_____. CHECK IF: Initial Authorization Concurrent Authorization and (If applicable) reference #: _____. Patient Name: ID Number: Date of Birth: ICD 10 Codes: Requesting / Ordering Provider: Taxonomy Code: NPI: Office Address: City: State: Zip: Contact Person: Phone: Fax: Service and Procedure Requests: Elective procedures and services subject to medical necessity review are listed on the back of this form.

3 Servicing / Treating Company or Provider:: Taxonomy Code: Date of Service: TBD. Office Address: City: State: Zip NPI: Contact Person: Phone: Fax: Facility/Place of Service: Taxonomy Code: Inpatient Outpatient Facility Address: City: State: Zip: Fax: HCPCS/CPT Procedure Code(s) Description Price: Length of Need: Example: L1833 Prefabricated Knee Brace $ 99. Fax this completed form, along with medical records documenting the clinical indications or medical necessity. If additional space needed, please attach additional prior authorization forms. 3000 E. Pine Ave. Meridian, Idaho 83642 208-345-4550. Mailing Address: Box 7408 Boise, ID 83707-1408. 2019 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association Form No. 12-104 (03-19). Services Requiring Prior Authorization Prior authorization for the following may not be required for specific employer contracts.

4 Complete list of codes requiring prior authorization: AIM Specialty Health: Sleep studies and sleep therapy Referrals to non-contracting providers are required for Nuclear cardiology Managed Care/POS plans only. MRI/MRA, CT/CTA, PET scans Urgent: CPAP, BIPAP or oral appliances for sleep apnea*. Urgent care is any request for medical care or treatment which the Spinal surgery*. time periods for making non-urgent care determinations could result Shoulder surgery*. in the following circumstances: Pain management procedures *. Could seriously jeopardize the life or health of the member, or Arthroscopy surgery*. the ability to regain maximum function, based on a prudent layperson's judgment, or *For groups participating in the AIM Specialty Health program, submit request 24/7 to AIM at or by phone In the opinion of a practitioner with knowledge of the member's (866) 714-1105 during business hours.

5 Medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. We encourage you to read PAP 241 at to Federal Employees Program (FEP): ensure your request is urgent. Inpatient hospital admission or SNF admission procedures : Gene therapy and cellular immunotherapy Stereotactic radiosurgery Air ambulance transport (non-emergent). Spinal cord stimulator Genetic testing for the diagnosis or management of existing Removal of kidney tumors medical conditions**. Hip and knee total joint procedures BRCA testing Nerve destruction by chemical agent Surgery for morbid obesity Surgical correction of congenital anomalies Dental surgery related to an accident Breast reduction or augmentation (not related to treatment of Eyelid surgery cancer)**.

6 Invasive treatment of lower extremity veins Reconstructive surgery for conditions other than breast cancer**. Nasal and sinus surgery Orthognathic surgery, bone grafts, osteotomies, surgery for TMJ**. Jaw surgery Oral maxillofacial surgery to jaws, cheeks, lips, tongue, roof and Reconstructive and cosmetic/ plastic surgery including breast floor of mouth reconstruction Orthopedic procedures of the hip, knee, ankle, spine, shoulder Surgery for snoring or sleep problems and all orthopedic procedures using computer-assisted Surgical treatment of obesity navigation**. Transplants (organ, tissue, cornea, etc.) Rhinoplasty, Septoplasty**. Gender reassignment services Varicose vein treatment**. Intensity modulated radiation therapy (IMRT) Outpatient intensity modulated radiation therapy (IMRT).

7 Certain other inpatient and outpatient surgical procedures Hospice care (inpatient and outpatient). Experimental or investigational procedures Gender reassignment services Investigational or experimental procedures requests will be reviewed Sleep studies performed outside of the home (basic and standard on a case-by-case basis with submission of supportive literature and plans only). clinical information. Organ/tissue transplants and Clinical trials for certain transplants Please refer to to search for our current Cardiac or Pulmonary Rehabilitation**. policy regarding a specific procedure or diagnostic test. Cochlear implants**. Services: External prosthetic devices**. Certain genetic testing Specialty DME, rental or purchase**. Bone stimulation for fracture healing Radiology, high technology including MRI, CT, PET scans (AIM)**.

8 Hyperbaric oxygen therapy **Applies to FEP Blue Focus plans only Non-emergent ambulance transport Please submit FEP prior authorization requests to the Blue Cross Infertility diagnostic testing and Blue Shield Association organization in the state where the Durable Medical Equipment: service will be performed. DME with a purchase or rent-to-purchase total greater than or You may request an Advanced Benefit Determination (courtesy equal to $1,000 review) for services not on the FEP prior authorization list that Hospital grade breast pumps are non-urgent and that are considered high cost (such as the Covered orthotics and prosthetics greater than or equal to $1000 procedures / services listed on this form). CPAP, BIPAP or Oral appliances for sleep apnea*. Questions? Call Blue Cross of Idaho 208-331-7535 or 800-743-1871.

9 Form No. 12-104 (03-19).