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Prior Approval / Pre-Notification / Pre-Service Requests - VERMONT
Requirements & Forms
We provide benefits for certain services, drugs and supplies only if approval is obtained in advance. This ensures the procedures are diagnostically appropriate, medically necessary and cost effective.
BlueCard Members: To look up out-of-area member's prior approval/pre-notification/pre-certification/pre-service requirements, please use the Medical Policy Router.
Medical Policies: developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease.
AcuExchange: Portal designed to allow providers the ability to view and submit prior approval and pre-notification requests electronically. The portal allows providers to see the status and documentation associated with the authorization submitted. Accessible by logging into the secure Provider Resource Center.
Prior Approval Lists
NEW for 2016! We have combined the prior approval lists for members of BCBSVT, TVHP, New England Health Plan, State of Vermont and University of Vermont Medical Center into two lists (as noted in the table below).
Prior Approval Form
Use the State of Vermont Uniform Medical Prior Authorization Form for all prior approval and pre-service requests, except radiology and pharmacy (details below).
Please note: although the form is titled "State of Vermont" use it for all member types, not just State of Vermont.
Some services also require a completed worksheet
These services require both a Uniform Prior Authorization Form and a completed worksheet:
- Chiropractic Plan of Treatment Worksheet
- Psychological Testing Additional Information Worksheet
- Initial Inpatient Rehabilitation Worksheet
- Inpatient Rehabilitation Continuation Worksheet
Send completed forms to:
|BCBSVT Integrated Health Management
P.O. Box 186
Montpelier, VT 05601
|Attention: Integrated Health Management
Radiology & Pharmacy Services Prior Approval
- Radiology services (elective) - CT, CTA, MRI, MRA, MRS & PET scans use AIM Provider Portal
- Pharmacy Services - Prior approval drug list
Questions or need help? Contact provider service at (800) 924-3494.