When certain medical services, treatments, or prescription drugs require prior approval, the Premera Blue Cross Prior Authorization Form becomes an essential part of your healthcare journey. This form allows your provider to request approval from Premera to ensure a procedure or service will be covered under your plan before it happens.
In this article, we’ll explain what the Premera prior authorization form is, who needs it, how to access and fill it out, and the best way to submit it—so you can avoid delays or claim denials.
What Is the Premera Prior Authorization Form?
The Premera Blue Cross Prior Authorization Form is an official document used by healthcare providers to request approval for services or medications that require pre-approval under your plan. This form contains:
- Member information (name, ID number)
- Provider information (name, NPI, contact)
- Medical necessity details
- Requested service, procedure, or drug
- Supporting documentation
Premera uses this form to evaluate the medical necessity, appropriateness, and coverage eligibility of the requested service.
When Is the Prior Authorization Form Required?
Not all services require prior authorization. Typically, this form is used for:
- Advanced diagnostic imaging (MRI, CT, PET scans)
- Elective surgeries
- Inpatient admissions
- Skilled nursing or rehab facility stays
- Durable medical equipment (DME)
- Home health care
- Specialty medications and infusions
- Behavioral health/substance use disorder treatments
Always check your plan documents or use the Premera Prior Authorization Tool on their website to determine if a PA is required.
How to Get the Premera Blue Cross Prior Authorization Form
1. Download from the Official Website
You can download the latest prior authorization forms directly from Premera’s website:
- Visit the Premera Blue Cross Provider Forms Page
- Scroll to the section labeled “Medical Prior Authorization”
- Choose the appropriate form (e.g., Medical Services, Behavioral Health, Pharmacy)
These forms are typically provided in fillable PDF format for easy online completion.
Types of Premera Prior Authorization Forms
Premera provides different forms based on service type:
| Form Type | Description |
| Medical Services PA Form | Used for surgeries, inpatient admissions, therapies |
| Pharmacy PA Form | Required for high-cost or specialty medications |
| Behavioral Health Form | For mental health or substance use disorder care |
| DME/Orthotics Form | For requesting medical equipment |
| Radiology PA Form | Required for CT, MRI, PET scans (often managed via eviCore) |
Make sure you’re using the correct form for the service being requested.
How to Fill Out the Prior Authorization Form
Most prior authorization forms will request the following:
- Patient Information
- Name
- Date of birth
- Premera member ID
- Name
- Provider Information
- Physician’s name
- National Provider Identifier (NPI)
- Office address and phone number
- Physician’s name
- Clinical Information
- Diagnosis and CPT/HCPCS codes
- Medical history or test results supporting necessity
- Treatment plan and duration
- Diagnosis and CPT/HCPCS codes
- Requested Service
- Specific procedure, treatment, or drug
- Service date or duration (if applicable)
- Specific procedure, treatment, or drug
- Attachments
- Lab results, chart notes, imaging results, etc.
- Lab results, chart notes, imaging results, etc.
Note: The form should be completed by your provider or clinic staff, not the member.
How to Submit the Prior Authorization Form
Premera accepts prior authorization requests through the following methods:
1. Online Portal (for Providers)
- Preferred method for fastest processing
- Providers log into the Premera Provider Portal
- Upload completed form and supporting documents
2. Fax Submission
- Fax number is listed on the form itself
- Common fax for medical PA: 888-742-1481 (verify with Premera)
3. Via eviCore (for Radiology & Imaging)
- Advanced imaging prior authorizations may be submitted through eviCore healthcare
- Visit www.evicore.com to start a requestong Does Approval Take?
Processing times vary depending on urgency and request type:
| Request Type | Timeline |
| Standard PA Request | Up to 15 calendar days |
| Urgent PA Request | Within 72 hours |
| Pharmacy PA | Typically within 1–3 business days |
Make sure all required fields and documents are attached to avoid delays.
Checking the Status of a Prior Authorization
You or your provider can check the status of your request by:
- Logging into your Premera Member Account
- Navigating to Claims & Authorizations
- Calling Customer Service (number on your Premera ID card)
Your provider may also receive fax or electronic updates during the review process.
What to Do If a Prior Authorization Is Denied
If your PA is denied, you have the right to appeal:
- Review the denial letter for the reason
- Discuss alternative treatments or appeal options with your provider
- Submit a written appeal with supporting documentation
- Receive a response (usually within 30 calendar days)
For urgent appeals, ask for an expedited review if your health is at immediate risk.
The Premera Blue Cross Prior Authorization Form plays a critical role in ensuring your healthcare services are covered and medically necessary. Whether it’s surgery, advanced imaging, or specialty medication, taking the right steps in the authorization process helps you avoid surprise bills and delayed care.
By working closely with your provider and using the proper form, you can streamline the process and get the care you need—on time and within network.