Prior Approval Authorization

There is a list of services, drugs and supplies that require approval from Blue Cross and Blue Shield of Vermont prior to administration and/or admission. If you do not get approval from Blue Cross and Blue Shield of Vermont before administration, benefits may be reduced or denied.

If marking a Prior Approval Request as urgent, please note:

• Marking a request as “urgent” does not guarantee immediate review; state guidelines permit us up to 48 hours to review a request marked as “urgent” (or one that is automatically treated as urgent under state rules).
• The most appropriate time to mark a request as “urgent” will be in situations involving urgently needed care (as defined by state regulations).
• We must respond to all prior approval requests within two business days, whether they are marked “urgent” or not.
• Please remember to submit requests before the member’s appointment.
• Please ensure a request for prior approval is complete and contains required clinical information, as this will expedite the process.

If using one of the paper forms below, fax the completed prior approval form(s) to (866) 387-7914.

• State of Vermont Uniform Medical Prior Authorization Form
• Psychological/Neuropychological Testing Additional Information Worksheet
  • This service requires completing the Prior Authorization form along with the worksheet

Additional Prior Approval Forms

• Radiology Services (elective) – CT, CTA, MRI, MRA, MRS & PET
• Pharmacy Services
  • Use CoverMyMeds (Member ID should include the last letter (usually V) followed by twelve numbers and the two-digit member number)
  • Call Vermont Blue Rx at (800) 313-7879

Resources

• Facts and Tips on the State of Vermont Uniform Medical Prior Authorization Form
• Services, Equipment & Supplies Requiring Prior Approval 
• Drugs Requiring Prior Authorization in the Medical Benefit
• 2024 Federal Employee Program List of Prior Approval Requirements for Standard and Basic Options
• 2024 Federal Employee Program List of Prior Approval Requirements for FEP Blue Focus
• 2025 Federal Employee Program (Federal and Postal Employee) List of Prior Approval Requirements for Standard and Basic Options
• 2025 Federal Employee Program (Federal and Postal Employee) List of Prior Approval Requirements for Blue Focus
• Quick Tips Sheet for using the searchable prior approval database

BlueCard Members

To look up out-of-area member's prior approval/pre-notification/pre-certification/pre-service requirements, please use the Medical Policy Router located on the Provider Policies page.

Pre-notification is a review conducted by Blue Cross and Blue Shield of Vermont before a member's admission to a facility for inpatient care, to confirm the appropriateness of the requested level of care and to assist with discharge planning and coordination of care for services not requiring prior approval.

We collect clinical information pertinent to the admission request. The information is reviewed in conjunction with nationally recognized health care guidelines. Providers are verbally notified of the determination of pre-notified services within three business days after obtaining all necessary information.

You can complete pre-notification in one of three ways:

1. Submit pre-notification requests electronically via the Prior Authorization Portal by logging in to the Provider Resource Center
2. Download the prior approval form; fax the completed prior approval form(s) to (866) 387-7914
3. Call us directly for a pre-notification request. If calling, have the member name and certificate number ready, as well as the clinical details. Call us at (800) 922-8778.

Additional Forms

• Census Reporting Requirements and Process
• Initial Inpatient Rehabilitation Worksheet
  • This service requires completing the Prior Authorization form along with the worksheet
• Inpatient Rehabilitation Continuation Worksheet
  • This service requires completing the Prior Authorization form along with the worksheet

BlueCard Members

To look up out-of-area member's prior approval/pre-notification/pre-certification/pre-service requirements, please use the Medical Policy Router on the Provider Polices page.

• Inpatient Prior Authorization Guide
• Outpatient Prior Authorization Guide
• Prior Authorization Portal User Guide

The Provider Passport Program for Advanced Imaging is part of our ongoing commitment to improving quality of care for our members while reducing administrative burden for our network providers. The program sets to simplify the process for participating providers to order MRIs, CAT scans, and other forms of radiology for patients, which should also speed up access to care for patients.

The Provider Passport Program was developed from valuable feedback from the provider community regarding the prior approval (PA) process. Under the program, providers with a history of excellence in adhering to evidence-based clinical pathways will be able to submit their advanced imaging requests via a streamlined process that substantially reduces their administrative burden. For providers with the strongest histories of evidence-based practice, the program will eliminate clinical review requirements for the duration of the pilot.

Tiers of Recognition

We calculated the initial recognition tiers based on the total volume of a provider’s advanced imaging requests together with the percentage of those requests that were approved.

• Tier 1 Providers: These providers had a denial rate of no more than 3% on PA requests for advanced imaging services. They have a streamlined PA submission process for advanced imaging modalities, where their requests receive automatic approval, with no clinical documentation or review required.
• Tier 2 Providers: These providers had a denial rate greater than 3% but less than 5%. They also receive automatic approval on PA submissions for advanced imaging requests. However, they need to submit clinical documentation with their requests. If the documentation submitted does not meet clinical guidelines, we will outreach with educational feedback as needed.
• Tier 3 Providers: All other providers had denial rates greater than 5% and continue to follow our current utilization review process.

Program Timeline

The program is effective for dates of service beginning February 1, 2020 and will run for an initial term of two years. Six months before the end of the current two-year term, we will review provider utilization patterns to determine each provider’s tier for the next two-year term.

Although we reserve the right to audit cases and adjust providers’ tier levels at any time, given the exceptional histories of all recognized providers, we do not expect any tier changes to occur during the term.

Performance Evaluation Criteria and Future Recognition

• Any advanced imaging requests that would have been denied outside of the Provider Passport Program will be considered a “conditional approval.”
• If a provider’s conditional approval rate is no more than 3% at the time of review, Blue Cross will recognize the provider as a Tier 1 provider in the next two-year cycle.
• If a provider’s conditional approval rate is greater than 3%, but no more than 5% at the time of review, Blue Cross will recognize the provider as a Tier 2 provider in the next two-year cycle.
• If a provider’s conditional approval rate is greater than 5%, Blue Cross will require a return to the standard (non-Provider passport Program) prior approval and utilization review process.

The initial pilot of the Provider Passport Program will run for two years and may expand to other authorization areas in the future. To learn more about this program, contact the Provider Relations team at (888) 449-0443, option #1 or providerrelations@bcbsvt.com.