Tips for Prior Authorization Requests

Use these tips to avoid delays when submitting prior authorization requests for inpatient and outpatient services. During the 2027 transition, BCBSND members may either migrate to new processes or not migrate and remain subject to current processes. Always use the member’s current ID card and check eligibility information to determine which instructions apply for the date of service.

Before you submit a request 

Confirm the member’s status first. Use the member’s current ID card and eligibility results to determine whether migrated or non-migrated instructions apply. Migrated members will have new information, such as a shorter member ID numbers (9 digits instead of 12 digits after the prefix) and new Customer Service phone numbers.

Verify eligibility and benefits. 

• Use Availity Essentials to verify eligibility and benefits.
• Call the Provider Contact Center for information not found in Availity. 

Confirm whether prior authorization is required. Choose the appropriate prior authorization information for migrated or non-migrated members before providing services. 

• Migrated members: Use the Availity Essentials Electronic Authorization application to check whether a service requires prior authorization and submit the request. View the Commercial Migrated Member Prior Authorization List .
• Non-migrated members: Use the PA Checkpoint Search to review requirements.

Include clinical documentation. Submit the required clinical documentation with your request. Reviewing applicable medical policies can help you determine what documentation is needed.

Watch for requests for more information. You may receive a request for additional information or clarification. Respond promptly to avoid delays.

Tips for Availity Essentials submissions 

• Submit the prior authorization request before the service is provided unless BCBSND communicates a specific exception. 
• Enter the member information carefully. If the member has a new ID card, use the current member ID number shown on that card. 
• Attach required clinical documentation at the time of submission when possible. 
• Monitor the Availity Essentials dashboard for determinations or requests for additional information. 
• If a submitted request does not require prior authorization, it will not be reviewed. Always check requirements before services are provided. 
• For submission errors, contact Availity Essentials support at 1-800-282-4548.
• For authorization status questions that cannot be answered from your Availity Essentials dashboard, contact the Provider Contact Center phone number on the back of the member ID card. 

For all members: Use the Authorization tool on Availity Essentials to find out if a procedure code or level of care requires prior authorization and submit your request quickly and easily. Some requests may be approved on the same day. You can also check the status of submitted requests and view determination letters.

Non-migrated members:
Continue to submit your requests through Availity Essentials and Predictal. You can use this resource guide to help.

Tips for fax requests

Migrated members: Use fax only when you cannot submit electronically through Availity Essentials due to the member’s status, or when a migrated member ID is not yet active in Availity. The prior authorization fax request form for migrated members will be available by Dec. 1, 2026.

Non-migrated members: When submitting a request by fax, continue to follow the existing process and complete the prior authorization request form for the appropriate level of service.

For all members:

1. Include all required clinical documentation, which is required for all prior authorization review requests.
2. All responses, decisions and requests for additional information will be sent by fax to the number provided on the request form.
3. All approvals, denials and requests for additional information may use the same fax format. Read each response carefully.
4. If additional information is required, your request will remain pended until the requested information is received.
5. In addition to your faxed response, you will also receive a determination letter which will contain clinical rationale.

Avoid common reasons for delay 

• Do not assume prior authorization requirements are the same for migrated and non-migrated members.
• Do not rely on a saved member ID card from a previous visit during the transition.
• Do not submit without checking whether prior authorization is required for the member’s status and date of service.
• Do not leave out required clinical documentation.
• Do not ignore requests for additional information or clarification.
• Do not rely on prior authorization as a guarantee of payment. Payment depends on member eligibility, benefits and other applicable requirements at the time of service.