Prior authorization is a request for pre-approval of certain tests, procedures, medical equipment, and medications ordered for you. Your provider must get that approval from Blue Shield before they proceed.
The Blue Shield team will review the prior authorization request to ensure that Medicare covers everything and that the care meets the best available clinical research. Without this pre-approval, Blue Shield may not pay for your medication or medical procedure. You will then have to pay out of pocket.
Who starts the prior authorization process?
Typically, your provider starts the process by submitting a request on your behalf. It will include details about your diagnosis and why the service or medication is needed. Prior authorizations usually take 1 to 3 days.
To know if your prior authorization has been processed, you have two options:
• Log in to your account. Under the "myblueshield" dropdown menu, select "Prior authorization." Here you can see a list of all prior authorization requests, as well as those that Blue Shield has approved.
• Call Customer Service or your doctor's office. They can help determine the status of your prior authorization. If you need help moving a prior authorization along call Customer Service to help.
What if my prior authorization is denied?
You have the right to appeal if Blue Shield denies your prior authorization request.
Learn more about Appeals and Grievances