Lowering costs using prior approval

Medical tests and treatments can be good for you, but some can do harm, not only to your health, but to your bank account. Just like in sports, sometimes it’s important to take a time out to review a situation in order to determine the next play.

When it comes to your healthcare, we’re on your team! Octave Blue Cross and Blue Shield is dedicated to making sure our members get the right healthcare at the right time and place. That helps keep healthcare costs lower for everyone.

Most of the time when you get care, your health plan stays in the background, but sometimes it is important for us to be sure the tests or treatments you are getting are right for you. For instance, getting several X-rays or other imaging tests can raise the level of radiation in your body, increasing your risk for cancer. To keep that from happening, in some situations we may ask doctors to contact us before ordering a test or starting a treatment. This is called prior approval.

Sometimes prior approval is needed to protect your health. Other times it may be needed to protect you from expensive tests or treatments when there are other, less expensive options available. Regardless, we will never ask for prior approval if you need:

• Emergency room services
• Ambulance services
• Urgent care
• Primary care
• Preventive care like covered screenings and immunizations
• Specialist and other practitioner office visits
• Diagnostic tests
  

We DO NOT want to stand in the way of needed care for our members or be an obstacle for doctors and hospitals. We DO want to ensure our members get the highest quality of care in the most appropriate settings and from the most appropriate medical professionals.

When a doctor or hospital submits information for prior approval, they will send information about why the test or procedure is needed. This clinical information is then reviewed by doctors at Octave Blue Cross. Most reviews are done very quickly so there is no delay in your healthcare. If the test or treatment is something that might be expensive or cause harm, the Octave Blue Cross doctor may ask if other evidence-based tests or treatments have been considered.

Prior approval is important because everyone on your care team evaluates whether you are getting the most appropriate care. And, it helps keep healthcare costs down, for you individually, and for everyone. It’s one way we are working to keep healthcare affordable.