X18509R07 (11/21)
Pre-authorization (PA) Request Form
Please refer to current pre-authorization lists to verify if service
Requires pre-authorization. Lists are located at
https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management
Effective May 1, 2019, Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) providers are required to use the
Availity
®
Provider Portal to submit preservice prior authorization requests. Faxes and phone calls for these requests will no
longer be accepted by Blue Cross. Please complete the clinical sections on this form and attach it to your request at
https://www.availity.com/
to ensure a timely review.
Providers outside of Minnesota without electronic access can fax this form, along with clinical records to support the request,
to (651) 662-2810.
This form should not be used for drug pre-authorizations (PA).
Request for Urgent Review: By checking this box, I certify that applying the standard review time may seriously
jeopardize the life or health of the member or the member’s ability to regain maximum function per Federal definition
of “Urgent”.
Member ID: ______________________________________________ Group number: _______________________
Member name: ___________________________________________ Date of birth: _________________________
Member address: _____________________________________________________________________________
Member city/state/zip: _________________________________________________________________________
Member phone: ____________________
Contact person: ____________________________________________________ Phone: ___________________
Servicing provider name: ________________________________________________________________________
Servicing provider ID/NPI number: ___________________________
Servicing provider address: ______________________________________________________________________
City/state/zip: _________________________________________________________________________________
Servicing provider phone: __________________________ Servicing provider fax: __________________________
Inpatient/Outpatient Facility name: ___________________________________ Facility ID______________________
Ordering Provider
Information
Ordering provider name: _________________________________________________________________________
Ordering provider ID/NPI number: ________________________
Ordering provider address: _______________________________________________________________________
City/state/zip: _________________________________________________________________________________
Ordering provider phone: ______________________ Ordering provider fax: _______________________
Services/Procedures/Items
Requested
HCPC/CPT
Code(s)
HCPC/CPT Code(s)
Description
Diagnosis
Code(s)
Start Date
mm/dd/yy
End Date
mm/dd/yy
Information/MSRP
(if applicable)
Blue Cross
®
and Blue Shield
®
of Minnesota and Blue Plus
®
are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
