Prior Authorization

Some services, procedures, equipment and medical drugs require prior authorization for coverage before providing the service. The ordering provider is typically responsible for obtaining prior authorization.

Beginning Jan. 1, 2027, providers will see BCBSND members who are either migrated to a new system, policies and processes, or who have not migrated and are using current processes. Always verify the member’s eligibility and benefits in Availity Essentials before checking prior authorization requirements or submitting a request.

Use the search tool below to verify whether the service requires prior authorization.

Before requesting prior authorization

  • Ask for the member’s current ID card at each visit. Do not rely only on a card saved from a previous visit. 
  • Verify eligibility and benefits in Availity Essentials before providing services.
  • Review applicable requirements and policies for the member’s status before providing services. Be sure to check:
    • Prior authorization requirements
    • Medical policy and clinical criteria
    • Retail and medical benefit drug (pharmacy) policy
  • Submit your request with the required supporting documentation. 

Migrated vs non-migrated members

Prior authorization requirements and workflows may differ based on the member’s migration status. Use the member’s current ID number and eligibility results to determine which instructions apply. 

Note: These instructions do not apply to the Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®)

Prior Authorization Instructions

Migrated members

  • Submit requests through the Availity Essentials electronic authorization workflow when the migrated member is active in Availity Essentials.
  • If a migrated member is not yet active in Availity Essentials for the date of service, an exception process is available to submit a request via fax. Details on this process and the fax forms will be available by Dec. 1, 2026. 
  • Prior authorization must be requested before services are provided. 
  • If we request additional information, respond with the required clinical documentation as soon as possible to avoid delays.

Non-migrated Members

  1. When a procedure, service or DME is ordered for a Commercial or Medicaid Expansion member, continue to use the search function to check precertification requirements associated with the member's contract. For best results, search using a procedure code. This search function does not apply to the Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®). 
  2. If the item indicates "precertification required," submit your request through Availity Essentials. You can use this resource guide to help.
  3. If you are temporarily unable to submit to an authorization for a non-migrated member through Availity Essentials, submit your request via fax:
         Inpatient Authorization Request
         Outpatient Authorization Request
         ABA Form - For FEP use only
  4. If you see no results for the code or search term entered, prior authorization is not required. Instead, refer to the medical necessity guidelines in the BCBSND medical policy.
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More Tips

Check out additional tips to assist with the review of a prior authorization request.

Additional resources for non-migrated members

Retail drug benefit authorizations
Medical drug benefit policies and prior authorizations
Genomic Testing (EviCore by Evernorth)
Predictal Resource Guide

Non-participating providers

Providers typically submit prior authorization requests on members' behalf. While not required for non-participating providers, it is appreciated by BCBSND members.

Want to know more about last year’s prior authorization activity?

The information found here shows prior authorization activity from the prior year for Qualified Health Plans (QHP) available through a Federally Facilitated Exchange and Medicaid Expansion plans. This information includes but is not limited to approval rates, denial rates, prior authorization appeal information.