Blue Cross Blue Shield (BCBS) is a federation of 34 independent, locally operated companies that collectively provide health insurance to over 115 million Americans. Because each BCBS plan operates independently, prior authorization requirements can vary significantly by state and plan. This makes navigating BCBS prior auth particularly challenging for providers.
Each BCBS plan has its own provider portal. Many BCBS plans also use Availity or NaviNet as intermediary portals. For out-of-state BCBS members (BlueCard program), the local BCBS plan processes claims but the home plan's PA requirements apply.
BCBS prior authorization requirements vary by state and plan, but generally require PA for advanced imaging, surgical procedures, specialty drugs, and DME. The BlueCard program for out-of-state members adds complexity, as providers must follow the home plan's PA requirements while submitting through local channels.
Imaging PA requirements vary widely across BCBS plans. Some use AIM Specialty Health, others use eviCore, and some manage imaging PA internally. The BlueCard program for out-of-state members requires checking the home plan's imaging PA requirements. This variability makes BCBS imaging PAs among the most complex to manage manually.
Always identify the specific BCBS plan (state) and check that plan's PA requirements. They vary significantly.
For BlueCard (out-of-state) members, the home plan's PA requirements apply even though the local plan processes the claim.
Use the provider portal specific to the member's BCBS plan for PA submissions.
Many BCBS plans use Availity or NaviNet. Check which portal the specific plan uses.
Keep documentation of the specific BCBS plan's imaging guidelines, as these are not standardized across the federation.
For complex cases, contact the specific BCBS plan's provider services line to clarify PA requirements.
Greenlight Medical submits prior authorizations directly to Blue Cross Blue Shield, assembles all required documentation, and tracks status in real time. No portal logins, no phone holds, no fax machines.
See Greenlight in ActionBCBS is a federation of 34 independent companies, each operating in different states with their own PA policies, clinical criteria, and submission processes. This means a BCBS member from Illinois may have entirely different PA requirements than one from Texas, even for the same procedure.
For BlueCard (out-of-state) members, you must follow the home plan's PA requirements but submit through local channels. This often means verifying requirements with the home plan while submitting through your local BCBS portal. Greenlight automates this by detecting the home plan and applying the correct rules.
Most BCBS plans require prior authorization for MRI, but the specific requirements, submission methods, and clinical criteria vary by state plan. Some plans use AIM Specialty Health for imaging PA, while others use eviCore or internal review.
The portal depends on the specific BCBS plan. Many use Availity, some use NaviNet, and others have their own dedicated portals. For imaging PAs, you may need to use a separate portal like AIM or eviCore. Greenlight automatically routes submissions to the correct portal.