Medical necessity and prior authorization timeframes and member responsibilities

Services requiring prior authorization

Prior authorization is a process through which Octave Blue Cross and Blue Shield determines the medical necessity of a covered healthcare service before the member receives the service. Prior authorization must be requested and approved before the member receives the healthcare services. If not, the claim will be denied. Please note that if a request for prior authorization is approved for medical necessity, the service still must meet all other coverage terms, conditions, and limitations (See section below for the Denial of Services with Prior Authorization).

Octave Blue Cross member contracts require prior authorizations for the following:

• Certain prescription medications
• Out-of-Network Providers paid as In-Network Provider

This list is not exhaustive.

Denial of services with prior authorization

Octave Blue Cross will approve a prior authorization request for coverage if medical necessity is supported. However, a request for prior authorization, if approved for medical necessity, does not guarantee payment of a claim for the service. A claim receiving prior authorization approval still must meet all other coverage terms, conditions, and limitations. Coverage for any such claim receiving prior authorization may be limited or denied if investigation shows that:

• a benefit exclusion or limitation applies
• the covered person ceased to be eligible for benefits on or before the date services were provided
• coverage lapsed for non-payment of premium
• out-of-network limitations apply
• any other basis specified in the policy applies to limit or exclude the claim.

If no additional information is requested, you will be notified of the determination in no later than two business days from the date the pre-service claim was received. Additional information regarding medical necessity and prior authorization can be found in the member's benefit certificate.

If you have need to verify whether your plan requires prior authorization, you may contact Customer Services at 800-800-4298 for more information.