Prior Approval Authorization

• Blue Cross and Blue Shield of Vermont Members (including New England Health Plan and Access Blue New England, when applicable)
  • Services, Equipment & Supplies Requiring Prior Approval
  • Drugs Requiring Prior Authorization (including Medical Benefit)
• Federal Employee Program Members
  • 2026 Federal Employee Program (Federal and Postal Employee) List of Prior Approval Requirements for Standard and Basic Options
  • 2026 Federal Employee Program (Federal and Postal Employee) List of Prior Approval Requirements for Blue Focus

Reminder: You do not need to submit a prior approval request if the service you are rendering or ordering does not require prior approval (see accordion below).

Prior approvals for medically necessary services (excluding prescription drugs or out of network services) are waived if a member is covered by a Vermont state regulated plan and the ordering provider meets specific requirements. Full details are in our provider handbook, under Section 12 "Act 111 – Primary Care Provider Waiver of Prior Authorization."

Billing Provider/Practice/Vendor

There are specific claim submission requirements that must be followed for a claim to bypass the prior authorization requirements. Details on submission requirements can also be found in Section 12 of our provider handbook.

A prefix listing, available on our Provider Forms and Resources webpage, under Claim Forms and Information, provides a full list of prefixes used for our members (Blue Cross VT, Federal Employee Program (FEP), New England Health Plan and Access Blue New England (NEHP/ABNE).

We offer a few options for providers to submit a prior approval and pre-notification of a scheduled admission. Please note that non-Blue Cross VT providers may only submit using the paper form below.

Online Submissions (available only to Blue Cross VT network providers)

• Prior Authorization Portal through the Provider Resource Center
• CBA Blue Dental
• CoverMyMeds for Vermont Blue Rx pharmacy
• Radiology Services (Carelon) – CT, CTA, MRI, MRA, MRS & PET

Paper Form Submissions

Only prior approvals managed by Blue Cross VT can be submitted using the below forms (see table in the Who Manages Prior Approvals and Pre-Notifications accordion above for more details). 

Fax the completed prior approval form(s) and support documentation to (866) 387-7914.

• State of Vermont Uniform Medical Prior Authorization Form
• Psychological/Neuropsychological Testing Additional Information Worksheet
  • This service requires completing the Prior Authorization form along with the worksheet

Phone Submissions

While not all services can complete a prior approval via the phone, available options include:

• CBA Blue Dental – (888) 222-9206
• CVS Caremark for FEP Pharmacy – (800) 624-5060
• Vermont Blue Rx Pharmacy – (800) 313-7879

Prior approval should always be secured prior to the service(s) being rendered. Please note that contracted providers and facilities are held financially responsible if a prior approval is required and not obtained and an appeal cannot be filed for lack of prior approval. However, we will conduct a retrospective review of medical necessity when one of the applicable circumstances listed in the provider handbook under Section 4, Retrospective Review, is met. The provider must contact us within a reasonable time, not to exceed 60 calendar days from the date of service, unless otherwise noted in Section 4.

Blue Cross VT does not manage prior approvals for BlueCard members – this includes New England Health Plan and Access Blue New England members who do not have a Vermont primary care provider. 

To look up out-of-area member's prior approval/pre-notification/pre-certification/pre-service requirements, please use the Medical Policy Router located on the Provider Policies page.

Pre-notification is a review conducted by Blue Cross and Blue Shield of Vermont before a member's admission to a facility for inpatient care, to confirm the appropriateness of the requested level of care and to assist with discharge planning and coordination of care for services not requiring prior approval.

We collect clinical information pertinent to the admission request. The information is reviewed in conjunction with nationally recognized health care guidelines. Providers are verbally notified of the determination of pre-notified services within three business days after obtaining all necessary information.

You can complete pre-notification in one of three ways:

1. Submit pre-notification requests electronically via the Prior Authorization Portal by logging in to the Provider Resource Center
2. Download the prior approval form; fax the completed prior approval form(s) to (866) 387-7914
3. Call us directly for a pre-notification request. If calling, have the member name and certificate number ready, as well as the clinical details. Call us at (800) 922-8778.

Additional Forms

• Census Reporting Requirements and Process
  • Sample Inpatient Census Report
  • Sample Emergency Room Census Report
• Initial Inpatient Rehabilitation Worksheet
  • This service requires completing the Prior Authorization form along with the worksheet
• Inpatient Rehabilitation Continuation Worksheet
  • This service requires completing the Prior Authorization form along with the worksheet

BlueCard Members

To look up out-of-area member's prior approval/pre-notification/pre-certification/pre-service requirements, please use the Medical Policy Router on the Provider Polices page.

• Inpatient Prior Authorization Guide
• Outpatient Prior Authorization Guide
• Prior Authorization Portal User Guide