BCBS Prior Authorization

To submit and document a BCBS prior authorization (PA) request for rehabilitation services through the Health Management portal, and to confirm whether the patient’s policy requires authorization.

Use this process when a patient has BCBS insurance and the office needs to verify or obtain prior authorization for rehabilitation/physical therapy services.

This process should be completed by the insurance verification / prior authorization coordinator, CA, or designated front office team member responsible for authorizations.

Log into the BCBS provider portal using the office credentials.

Purpose: To access the patient’s benefit and authorization tools.

From the main portal, click Health Management.

Purpose: This section contains the authorization and specialty care request options.

In the Member ID Prefix field, enter the first 3 characters of the patient’s insurance policy number.

Examples:

Purpose: This directs you to the correct BCBS plan and authorization pathway.

Click the Diagnostic and Specialty Care link. This will open in a new window.

Purpose: This is where rehabilitation requests are started.

Once the patient information is loaded, select Rehabilitation and then click Start Order Request.

If Rehabilitation cannot be selected:

This means the patient’s policy does not require prior authorization for rehab.

In that case:

Purpose: To confirm whether authorization is required before moving forward.

Review the patient’s information for accuracy, then click Continue.

Purpose: To ensure the request is attached to the correct patient.

Enter the patient’s chief diagnosis code.

Purpose: To identify the condition being treated and the service being requested.

For Therapy Type, select Physical Therapy, then save.

Purpose: To classify the request correctly.

Question: Is this a request to provide autism services for a confirmed diagnosis of autism spectrum disorder or pervasive developmental disorder...?

Select: No

Purpose: This question does not apply to standard chiropractic rehab requests.

Question: Was an initial evaluation performed by a therapist or a licensed qualified provider of therapy services?

Select: Yes

Purpose: Confirms that the patient has already been evaluated.

Enter the patient’s initial evaluation date.

Refer to:

Purpose: This supports medical necessity and treatment timing.

For Functional Tool, select:

ODI – Oswestry Low Back Pain Disability Questionnaire (0–50 points)

Then:

Purpose: This provides measurable functional limitation data required to continue.

Search for:

Purpose: To assign the request to the correct provider.

Under Provider Results, choose the first option.

Then check the box: Ordering provider is also the Treating Therapist

Purpose: To correctly link the rendering and ordering provider.

Question: Will the Servicing Facility be billing for the request?

Select: Yes

Purpose: Confirms the treating office is the billing location.

The office should populate automatically.

Select it and confirm it is listed as an office, then continue.

Purpose: Ensures the request is tied to the correct facility.

Question: Which of the following best describes the primary purpose of therapy?

Select: Rehabilitation

Purpose: Identifies the overall treatment goal.

Question: Will any of the following be used as a primary treatment?

Select: None of these apply

Purpose: Confirms that no special treatment category applies.

Question: What is the complexity level of the evaluation or E&M equivalent that was completed for this request?

Confirm this option with Dr. Mays, then select:

Moderate complexity (CPT 97162 or E&M 99203, 99204)

Purpose: Ensures the clinical level selected matches the provider’s evaluation.

Question: Did the patient have a surgical procedure in the last three (3) months related to the conditions for which services are being requested?

Select: No

Purpose: Determines whether post-surgical criteria apply.

Question: Did the onset of the injury or condition occur within the last six (6) months?

Select: Yes

Purpose: Supports the rehabilitation timeline and medical necessity.

Question: Is the requested treatment for a complex neurological, medical, or multi-trauma condition?

Select: No

Purpose: Confirms this is a standard rehab request.

Question: Select all conditions expected to impact treatment

Select: None of these apply

Purpose: Indicates there are no additional complicating factors affecting care.

Complete all required attestations and click Save.

Purpose: Finalizes the clinical details required for submission.

If prompted for both the patient’s phone number and email, select Unable to provide both in order to continue.

Purpose: Allows the request to move forward if complete contact details are not available.

Select Preview and carefully verify that all information is correct.

Check:

Purpose: Prevents errors before submission.

Submit the order.

Purpose: Sends the PA request for review.

In most cases, you should receive immediate results.

When prompted:

Purpose: Completes the authorization process and records the result.

After completion, document the outcome in the patient chart.

Include:

Purpose: Maintains accurate records for billing and follow-up.