Blue Cross and Blue Shield of Minnesota
and Blue Plus
Prior Authorization/Precertification Request
bluecrossmn.com
Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
BMNPEC-0026-18 January 2019
Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) prior authorization: 866-518-8448; Fax: 1-800-964-3627
To prevent delay in processing your request, please fill out this form in its entirety with all applicable information.
Is this admission/procedure/service/item required urgently? YES / NO By definition urgently needed services mean that if the
standard timeframe was applied it may seriously jeopardize the member’s health or ability to regain maximum functioning or subject the
member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.
Address: City, State ZIP code:
Member ID: Contact phone: DOB:
Additional member information:
Office contact name: Office phone: Office fax:
Office contact name: Office phone: Office fax:
Facility contact name: Facility phone: Facility fax:
Address: City, State ZIP code:
Requested service (For type of service, check all that apply.)
Date/date range of service:
CPT code(s) (include requested units):
Type of service: ☐ Outpatient ☐ Inpatient ☐ Skilled nursing facility
☐ Long-term services & supports/long-term care ☐ Home health
☐ Durable medical equipment ☐ Diagnostic study ☐ Hospice
☐ Office visit ☐ Personal care services ☐ Other:
Place of service: ☐ Hospital ☐ Ambulatory surgery center ☐ Office
☐ Home ☐ Independent lab ☐ Nursing facility ☐ Other:
Please submit all appropriate clinical information, provider contact information and any other required documents with this
form to support your request. If this is a request for extension or modification of an existing authorization from Blue Cross,
please provide the authorization number with your submission.
This area is reserved for the definition of what is considered expedited, urgent or emergent.
Emergent — Use for all nonelective inpatient admissions only when provider indicates that the admission was urgent, emergent or
expedited (for admission on same day).
Urgent — Use for outpatient services only when provider indicates that the service is urgent, emergent or expedited.
Disclaimer: Authorization is based on verification of member eligibility and benefit coverage at the time of service and is subject to Blue Cross
claims payment policy and procedures.
