694 Form

Prior authorization request forM Assisted reproductive technology services or
preimplantation genetic testing
Non-participating providers (commercial members):
Fax completed form to 1-800-836-1112 Blue Cross participating providers:  Use Authorization Manager (see below)  For Federal Employee Program members living outside of Massachusetts: Fax completed form to 1-888-282-1315 WHEN TO USE THIS FORM Complete and submit this form when requesting authorization for assisted reproductive technology services or preimplantation genetic testing. For commercial members, refer to medical policies 086 and 088 for coverage criteria.
For Federal Employee Program members, refer to member plan brochures at fepblue.org. Blue cross blue shield of Massachusetts providers must use Authorization manager eTool To request initial authorization for these services, Blue Cross Blue Shield of Massachusetts providers should use Authorization Manager, an electronic technology used to review authorization requirements, request authorizations, upload clinical documentation to an existing case, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines. To ensure the request is processed accurately and quickly:  Enter the facility’s NPI or provider ID for where services are being performed.  Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.  Include this form with your submission via Authorization Manager. Authorization Manager Resources  Refer to our Authorization Manager page for tips, guides, and video demonstrations. Provider information Provider name

Provider NPI Provider address

Facility NPI Facility name

Facility address □Check box if same as provider address Provider contact name Phone with extension Fax *Our policy requires that we handle transmission of protected health information (PHI) in accordance with HIPAA protections. Member information Member name Member date of birth Member health plan ID Partner’s name

Partner’s date of birth Print form Clear form fields

Questions You must attach clinical information to support medical necessity for the following
Member is undergoing chemotherapy or other treatment that is expected to render them infertile? □ Select all that apply: Single □ Same sex couple □ Female □ Male □ Ovulatory disorder? □ Ovulatory disorder with exposure to sperm without conception for:
6 cycles <35 □ OR 3 cycles ≥35 □ Biological female with no biological male partner with exposure to sperm (IUI) for: 6 cycles <35 □ OR 3 cycles ≥35 □ Biological female with biological male partner inability to conceive, 12 months <35 □ OR 6 months ≥35 □ Has either partner been sterilized? OR
Has either partner had a sterilization reversal?
□Yes □ No □Yes □ No Specific infertility diagnosis and procedure code(s): Treatment to date: This is required for all requests, please attach in your submission Donor egg: Please indicate if our member is the sole recipient of the donor eggs Donor egg (from egg bank) □ Yes Known donor: Sole recipient
□ Yes □ No Donor age: Anonymous (Agency) donor: Sole recipient □Yes □ No Continued storage □Egg (89346)□Embryo (89342)□Sperm (89343) Must include the following: Day 3 FSH and E2 (highest and most recent) Uterine cavity evaluation (sonohysterogram/HSG, HyCosy, 3D U/S, FemVue or Hysteroscopy), within the last 24 months. Semen Analysis (for ICSI we only accept Kruger Morphology and there must be at least 2 samples) Ovarian Reserve Testing: required for members age 40 but <44 years old. One of the below tests is required yearly with updated day 3 FSH and E2 after 6 months has passed. Option 1. Clomid Challenge test: Day 3 FSH & E2 results, clomid 100 mg P.O. days 5-9, and a day 10 FSH & E2 results. Option 2. Day 3 FSH, estradiol, and antral follicle count (AFC) done on the same day, AND an anti-mullerian hormone (AMH) drawn within 1 month. Blue Cross Blue Shield of Massachusetts refers to Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc., and/or Massachusetts Benefit Administrators LLC, based on Product participation. ® Registered Marks of the Blue Cross and Blue Shield Associate. ©2026 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. MPC080723-1X (rev. 5/26) Anticipated procedures that are medically necessary (check only the requested procedure) □IUI to IVF conversion (medical emergency) Fertility Preservation □Cancer or □ other: __ □Egg □ Embryo □ Sperm □Reciprocal IVF □Reciprocal FET

IVF (with a Fresh Transfer)
□S4015 □58970, 58974 □89258 (cryo) □89342 (storage) IVF Freeze All □S4021 □58970 □S4011 (out of state only) □89258 (cryo) □89342 (storage) Frozen Embryo Transfer (FET) □S4016 □58974 □S4037 Number of frozen eggs/embryos remaining: __ □MESA □TESE □Donor Sperm S4026 ICSI □S4022 (in state) □89280/1 □Assisted Hatching (89253) Egg thaw with fertilization and transfer or freeze □S4037, S4022 □89356, 89280/1, 89258, 89342 □58974 Embryo TBR (thaw/biopsy/refreeze) MUST select PGT (see next box) □S4018 □89352, 89290/1, 89258 Preimplantation Genetic Testing □PGT-M (84999) □PGT-SR (88299) □PGT-A (81228) Specific genetic dx: ____