Prior Approval Program
Importance of Prior Approval
Certain services, supplies, and prescription drugs require advance (prior) approval before benefits are provided. This ensures the services are diagnostically appropriate, medically necessary, and cost effective.
Prior Approval Requirements
To determine what prior approval requirements apply to a patient/member, refer to the table below.
**NOTE: Referral authorizations (BCBSVT refers to as prior approval) for members with New England Health Plan should only be sent to BCBSVT if the member has selected a primary care provider located in the State of Vermont. If the member has selected a PCP in any other state the local Blue Cross and Blue Shield Plan’s prior approval/referral authorization guidelines will apply and requests need to be submitted directly to that Plan.
- BCBSVT network providers get prior approval for you. If the Vermont network provider fails to get prior approval for services that require it, the provider may not bill you.
- If you use an out-of-network provider or out-of-state provider, it's your responsibility to get prior approval. Failure to get prior approval could lead to denial of benefits. If you can show that the services you received were medically necessary, we will provide benefits.
Requesting Prior Approval
- BCBSVT network providers must send appropriate documentation to BCBSVT.
- When receiving care from a non-network provider or an out-of-state provider, you must complete the appropriate form; you may also get the form by calling our customer service team.
- The BCBSVT medical staff will review the information and respond in writing to you and your provider.
Check Prior Approval Status
To check prior approval status, call customer service at (800) 247-2583.