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Pre-authorization

Medical and Behavioral Health Pre-authorization Lists

Obtaining pre-authorization information for out-of-area (BlueCard®) members:

Use our online tool to be automatically routed to the home plan's pre-authorization / pre-certification requirements. Launch the tool

Medical Pre-Authorization Forms
Form Description Instructions

Pre-authorization Request Form

Medical, surgical or DME services:

Home Health and Ancillary Therapies:

  • PDF version to print and fax

This form is used when a condition requires a pre-authorization. A limited number of services require a pre-authorization.

Submit completed forms:

• Securely online, or
• By Fax to:
       
    •

1 (877) 663-7526 for Uniform Medical Plan (UMP) members
    •

1 (800) 453-4341 for all other members
Pre-Authorization Fax Cover Sheet This form is used when faxing the Pre-Authorization Request Form Use the Pre-Authorization Fax Cover Sheet to fax your Request form or supporting documents.

Statement of Medical Necessity for Oncotype DX (PDF)

This form is used to facilitate medical necessity for Oncotype Dx® Breast Cancer Assay. Codes include S3854 and 84999.

 Fax completed forms to 1 (800) 453-4341

 

Behavioral Health Pre-authorization Forms
Form Description Instructions

Outpatient Treatment Plan Request (PDF)

 

 

This form is for Federal Employee Program (FEP) members. 

A treatment plan is requested, but not required, for members with FEP primary coverage.

Call FEP Customer Service at 1 (877) 668-4654 in order to verify the type of coverage, benefits, eligibility, co-payments, and deductible.

Please fax the completed form to 1 (888) 496-1540.
Behavioral Health Treatment Plan Request

This form is for members who require an authorization for behavioral health outpatient treatment, including chemical dependency.

Submit this form to Regence for authorization of continued services.

Please call Regence Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions. 

Complete the Treatment plan request form securely online or you may download the form (PDF) and submit by fax to Regence Behavioral Health 1 (888) 496-1540.

 

 

Note: To print a PDF document, you need Adobe® Reader®. Download it now for free.
 

Regence BlueShield. All rights reserved. Regence BlueShield serves much of the state of Washington and is an Independent Licensee of the Blue Cross and Blue Shield Association.
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