Prospective Request (Pre-certification)
Prospective Request (also known as Pre-Certification) is the exchange of information between providers and BCBSWY to establish medical appropriateness, necessity of services and benefits prior to patient care.
View the Prospective Request Guideline to help you determine BCBSWY’s requirements for prospective requests. The guideline is updated regularly on our website. We recommend referring to the website each time you consider submitting prospective requests to determine BCBSWY’s requirements. This guide is subject to change without notice.
Authorization numbers are included for services which do not require BCBSWY prospective requests but may be necessary for use at your practice.
For services which do require BCBSWY prospective requests, complete the
Prospective Request Form and submit it as instructed. Please only mark a prospective request URGENT if failure to receive treatment will result in a life or limb threatening situation. Otherwise, the request may be delayed in processing. (BCBSWY does not recognize scheduling conflicts as an urgent request.)
BCBSWY’s Medical Policies are also available for your reference online. These Medical Policies are used by BCBSWY to review prospective requests and are searchable by title, CPT code and identification number.
Benefits will be denied if the patient is not eligible for coverage under the benefit plan on the date services are provided or if services received are not medically appropriate and necessary. Inclusion of a service on this guideline does not guarantee payment.
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