Prior authorization is a plan's advance review of a requested service. For Blue Cross or Blue Shield Medicare Advantage, use the process of the company issuing your exact plan. There is no universal BCBS authorization form for every state and product.
Check three separate requirements
| Requirement | Meaning |
|---|---|
| Network participation | The provider participates in the applicable plan. |
| Referral | A required direction to another professional. |
| Prior authorization | The plan reviews specified care in advance. |
Meeting one requirement does not necessarily satisfy the other two. Ask the office which request it will submit and whether your planned service, site and date match the request.
Prepare a complete submission
- Exact member and plan information.
- Requested service, provider and location.
- Supporting clinical records from the treating professional.
- Reason an expedited decision may be needed.
Keep the submission reference and date. Avoid putting medical identifiers into public contact forms. If more information is requested, confirm who will send it and how receipt will be documented.
Understand the decision timeline
CMS's 2026 medical prior-authorization rules generally require affected payers, including Medicare Advantage organizations, to decide standard requests within seven calendar days and expedited requests within 72 hours. Applicable exceptions and request types matter; these are not universal deadlines for every appeal or payment dispute.
After the response
Check which service, quantity, location and dates an approval covers. Authorization does not by itself waive deductibles or establish coverage after enrollment ends. If denied, request the written reason and follow the appeal instructions. Ask about expedited review when waiting could seriously harm your health under the applicable criteria.
For an emergency, seek emergency care rather than delaying to obtain routine authorization. For scheduled care, confirm status before the appointment and keep the written decision with your coverage records.
Related coverage questions
- How to Verify Your Medicare Coverage and Plan Enrollment
- A Medicare Medical Claim Was Denied: What to Do Next
- Medicare HMO and PPO: Networks, Referrals and Costs