CurrentAnthemPolicy N/A

FEP Blue Precertification / Prior Approval Requirements — New Hampshire

Defines prior authorization (precertification) requirements for inpatient and outpatient services under the FEP Blue Cross Blue Shield plan in New Hampshire, including which services require prior approval and contact information for authorization.

Policy Summary

PayerAnthem

PolicyFEP Blue Precertification / Prior Approval Requirements — New Hampshire

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification prior to inpatient admission or notify the plan within two business days for emergency admissions; call 800-860-2156 for authorization.

SourceLink

Inpatient & select outpatientservice categories requiring prior approval

ABA requires prior approvalABA policy status

$100Blue Focus penalty

2 business daysemergency notification timeframe

Prior Approval and Coverage Criteria

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ALL of the following

Inpatient admissions for mental health and substance abuse services require prior approval based on medical necessity.
Residential Treatment Centers: precertification must be obtained prior to admission; members must be enrolled and participating in case management and facility must meet licensing/accreditation and provide preliminary treatment and discharge plans.

ALL of the following

ABA benefits are included for autism spectrum disorder and prior approval is required for all ABA therapy.
Clinical review is required to determine medical necessity; parents/guardians must be engaged in the treatment plan.
ABA and related services are excluded when provided for conditions other than autism spectrum disorder or when provided as part of an educational program or in school settings.

ALL of the following

Under Blue Focus, when prior approval is not obtained for listed professional and outpatient facility services (drugs excluded), a $100 penalty will be applied to the claim once services are approved.
Prior approval is not required for kidney or cornea transplants.

ALL of the following

General authorization phone: 800-860-2156 (8AM-7PM ET) Monday-Friday; refer to MHSA and ABA team contact numbers for behavioral health and ASD/ABA approvals.

Precertification, Authorization, and Provider Responsibilities

Prior Authorization

Precertification / Prior Approval Required

Precertification (precert) is the contractual requirement that the member or provider contact the Local Plan where services will be performed before an inpatient hospital admission, or within two business days following the admission when the hospital admission is an emergency. Precertification is also used as the prior-approval process for certain outpatient services. Contact for precertification/prior approval: Phone: 800-860-2156 (8AM - 7PM ET) Monday–Friday. FAX: 800-732-8318.

Precert required before inpatient admission or within two business days after an emergency admission
Precert/prior-approval applies to specified outpatient services (see outpatient prior approval lists)
Precert/prior-approval phone: 800-860-2156 (8AM - 7PM ET) Mon–Fri; Fax: 800-732-8318

Prior Authorization

Inpatient Prior Approval

For inpatient admissions (including Long Term Acute Care and obstetric deliveries beyond federally mandated minimum length of stay) prior approval is required. Emergency admissions require Plan notification no later than two business days after admission. Prior approval is also required for all inpatient admissions for solid organ and bone marrow/stem cell transplants (including kidney-only transplants).

Prior approval required for all inpatient admissions, including LTAC and OB stays beyond federal minimum LOS (including newborn stays beyond mother's stay)
Emergency admissions: notify Plan within 2 business days after admission
Prior approval required for inpatient solid organ and bone marrow/stem cell transplants (including kidney-only)

Prior Authorization

Outpatient Prior Approval (Examples)

Certain outpatient procedures and services require prior approval under the Standard, Basic, and/or Blue Focus contracts. Examples include, but are not limited to: air ambulance transport (non-emergent); applied behavior analysis (ABA); gene therapy and cellular immunotherapy; hospice care; organ/tissue transplants (except kidney or cornea where noted); outpatient IMRT for specified cancers; outpatient surgery for morbid obesity; selected surgical services; radiology high-technology (MRI, CT, PET) under Blue Focus; specialty DME; cochlear implants; outpatient residential treatment centers; and others. Under Blue Focus, a $100 penalty may apply to professional and outpatient facility claims when prior approval is not obtained for listed services (drugs excluded).

Outpatient prior approval examples: Air ambulance (non-emergent); ABA; gene therapy/cellular immunotherapy; IMRT (specific cancers); outpatient surgery for morbid obesity; selected surgical services (e.g., breast reduction/augmentation not cancer-related, gender reassignment, orthognathic, reconstructive procedures); radiology high-technology (MRI/CT/PET) under Blue Focus; specialty DME; transplants (except cornea and kidney in some cases)
Blue Focus: $100 penalty applied to professional and outpatient facility claims if prior approval not obtained for listed services (does not apply to drugs)

Prior Authorization

Behavioral Health Authorization (MHSA)

All inpatient admissions for mental health and substance abuse (MHSA) to an inpatient treatment facility require prior approval based on the Service Benefit Plan description of medical necessity. For MHSA authorization and precertification, contact the MHSA team: Phone: 800-424-4011 (8AM - 5PM ET) Monday–Friday. FAX: 866-793-0469. Telehealth access information: go to www.fepblue.org/telehealth or call 855-636-1579 (TTY: 855-636-1578).

Prior approval required for all MHSA inpatient admissions based on medical necessity
MHSA authorization phone: 800-424-4011 (8AM - 5PM ET) Mon–Fri; Fax: 866-793-0469
Telehealth access: www.fepblue.org/telehealth or 855-636-1579 (TTY: 855-636-1578)

Prior Authorization

Applied Behavior Analysis (ABA) Prior Approval

Applied Behavior Analysis (ABA) services require prior approval for all ABA therapy. Benefits include assessments, evaluations, and treatments. Clinical review is required to determine medical necessity, and parents/guardians must be engaged in the treatment plan. For ABA prior approval and related inquiries contact the ASD Team: Phone: 844-269-0538 (8AM - 7PM ET) Monday–Friday. FAX: 866-582-2287.

Prior approval is required for all ABA therapy and related services (assessments, evaluations, treatments)
Clinical review required for medical necessity determination
Parents/guardians must be engaged in the treatment plan
ABA/ASD Team phone: 844-269-0538 (8AM - 7PM ET) Mon–Fri; Fax: 866-582-2287

OpenPayer

FEP Blue Precertification / Prior Approval Requirements — New Hampshire

Prior Approval and Coverage Criteria

Service Codes and Coding Notes

Precertification, Authorization, and Provider Responsibilities

Key Definitions