Prior Approval Program

Importance of Prior Approval

Certain services, supplies, and prescription drugs require advance (prior) approval before benefits are provided. This ensures the services are diagnostically appropriate, medically necessary, and cost effective.

Prior Approval Requirements

To determine what prior approval requirements apply to a patient/member, refer to the table below.

Members OfPrior Approval Requirements
  • Blue Cross and Blue Shield of Vermont
  • TVHP
  • New England Health Plan (NEHP)**/ Access Blue New England (ABNE)**
  • State of Vermont
  • University of Vermont Medical Center

Federal Employee Program

Only require Prior Approval on certain services, which are based on medical necessity. For a complete quote of benefit information, please contact The Federal Employee Program at (800) 328-0365.

**NOTE:  Prior Approvals for members with NEHP/ABNE should only be sent to Blue Cross and Blue Shield of Vermont if the member has selected a primary care provider located in the State of Vermont.  If the member has selected a PCP in any other state the local Blue Cross and Blue Shield  Plan’s prior approval guidelines will apply and requests need to be submitted directly to that Plan.

 

Prescription Drugs

 

Who's responsible?

  • Blue Cross and Blue Shield of Vermont network providers get prior approval for you. If the Vermont network provider fails to get prior approval for services that require it, the provider may not bill you.
  • If you use an out-of-network provider or out-of-state provider, it's your responsibility to get prior approval. Failure to get prior approval could lead to denial of benefits. If you can show that the services you received were medically necessary, we will provide benefits.

 

Requesting Prior Approval

  • Blue Cross and Blue Shield of Vermont network providers must send appropriate documentation to Blue Cross and Blue Shield of Vermont.
  • When receiving care from a non-network provider or an out-of-state provider, you must complete the appropriate form; you may also get the form by calling our customer service team.
  • The Blue Cross and Blue Shield of Vermont medical staff will review the information and respond in writing to you and your provider.

 

Check Prior Approval Status

To check prior approval status, call customer service at (800) 247-2583.