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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.

Determine if Prospective Request is Required:

View the Prospective Request Guideline to help you determine BCBSWY’s requirements for prospective requests. This guideline is updated regularly on our website. We recommend referring to the website each time you consider submitting prospective requests to determine BCSWY’s requirements.

Authorization numbers are included for services which do not require BCBSWY prospective requests but may be necessary for your practice.

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.

Complete a Prospective Request:

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.

Processing a Prospective Request:

When BCBSWY receives a prospective request from a provider, it will be reviewed by our clinical staff. BCBSWY’s Medical Policies are used in this review. These policies are available online for providers and are searchable by title, CPT code and identification number.

A determination (approved or denied) will be rendered from the information submitted:

  • Non-urgent prospective requests can take up to 14 calendar days from date of receipt to be processed.
  • Urgent* prospective requests can take up to 3 calendar days from date of receipt to be processed.
  • The provider and member will be notified in writing of the determination (via U. S. Mail).
Contact Us:

The provider or member is encouraged to contact BCBSWY Member Services at
800-442-2376 if a determination has not been received within the timeframes shown above.

* For further explanation of the urgent prospective review criteria, please visit the
U. S. Department of Labor.

 

 

 

 

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