Health insurance can feel overwhelming, especially when it comes to prior authorizations—a process that can delay care if you’re not prepared. If you’re insured through Premera Blue Cross, understanding their prior authorization policy can help you avoid surprises, get quicker approvals, and ensure your care is covered.
In this guide, we’ll explain what prior authorization is, which services typically require it under Premera Blue Cross, how the process works, and how you can check the status of your authorization requests.
What Is Prior Authorization?
Prior authorization (PA)—also called pre-approval or pre-certification—is when your health insurance provider requires review and approval before you receive certain medical services, prescriptions, or procedures.
The purpose is to:
- Confirm the treatment is medically necessary
- Ensure you’re receiving cost-effective care
- Prevent unnecessary or duplicate procedures
Without prior authorization, your insurance may deny payment, and you could be responsible for the full cost.
Does Premera Blue Cross Require Prior Authorization?
Yes. Premera Blue Cross requires prior authorization for certain medical services, prescription drugs, and behavioral health treatments. These requirements may vary by plan type and service category.
Services That Commonly Require Prior Authorization:
- Inpatient hospital admissions
- Advanced imaging (MRI, CT, PET scans)
- Durable medical equipment (DME)
- Specialty medications (especially injectables or infusions)
- Elective surgeries
- Home health services
- Physical, speech, and occupational therapy beyond a certain limit
- Mental health and substance use disorder treatments
- Skilled nursing facility stays
Always check your specific plan or contact customer service to verify whether a service requires authorization.
How to Request Prior Authorization with Premera
Prior authorization requests are typically handled by your healthcare provider, not the patient. However, it’s important for you to understand the process to ensure care is not delayed.
Step-by-Step Process:
- Provider Submits Request
- Your doctor or specialist submits the request through the Premera Provider Portal or via fax.
- Your doctor or specialist submits the request through the Premera Provider Portal or via fax.
- Medical Review
- Premera reviews the request using clinical guidelines and checks for medical necessity.
- Premera reviews the request using clinical guidelines and checks for medical necessity.
- Decision Notification
- Approval, denial, or request for additional information is issued within 2 to 15 business days, depending on urgency.
- Approval, denial, or request for additional information is issued within 2 to 15 business days, depending on urgency.
- Notification to Patient and Provider
- Both you and your provider will receive the decision. You can also check status online.
- Both you and your provider will receive the decision. You can also check status online.
How Long Does Premera Take to Approve Prior Authorization?
The timeline depends on the type of service:
| Request Type | Decision Timeline |
| Standard (non-urgent) | Within 15 calendar days |
| Urgent (medically necessary) | Within 72 hours |
| Prescription drug prior authorization | Typically within 24 to 72 hours |
In some cases, Premera may ask for additional documentation, which can extend the timeframe.
How to Check the Status of a Prior Authorization
You can check the status of your prior authorization request by:
- Logging into your Member Account at www.premera.com
- Navigating to Claims & Authorizations
- Selecting the specific service or provider to view current status
- Contacting Member Services at the number on your ID card
Your healthcare provider can also check status via their Premera Provider Portal.
What Happens if You Skip Prior Authorization?
If a service requiring prior authorization is performed without approval:
- Premera may deny the claim
- You could be held 100% financially responsible
- The appeal process could delay treatment or reimbursement
Always confirm with your provider before receiving services, especially for non-emergency procedures.
Prior Authorization for Prescription Medications
For specialty drugs, high-cost medications, or drugs not on the standard formulary, Premera may require:
- Clinical documentation
- Step therapy (trying lower-cost alternatives first)
- Quantity limits
Your provider or pharmacist will typically initiate this request on your behalf. Use the Premera Drug Lookup Tool online to check if a medication requires pre-approval.
How to Appeal a Denied Prior Authorization
If Premera denies a prior authorization request, you have the right to appeal the decision.
Steps to Appeal:
- Review the denial letter to understand the reason
- Contact Member Services for clarification
- Submit a written appeal with supporting documents
- Wait for a decision (typically within 30 days)
If urgent, you may be eligible for an expedited appeal.
Understanding how prior authorization works with Premera Blue Cross is key to avoiding delays in care and unexpected bills. Whether it’s for an MRI, a new medication, or outpatient therapy, getting approval ahead of time ensures a smoother healthcare experience.
To stay informed:
- Use the online member portal to check requirements
- Communicate clearly with your healthcare provider
- Don’t hesitate to follow up on pending requests
Being proactive with prior authorization can help you stay on top of your health while avoiding coverage complications.