CurrentAnthemPolicy N/A

FEP Kentucky Precertification / Prior Approval Requirements

Defines precertification and prior approval requirements for inpatient and outpatient services under the Federal Employee Program (FEP) Blue Cross Blue Shield in Kentucky; affects members, providers, and facility billing for services listed in the document.

Policy Summary

PayerAnthem

PolicyFEP Kentucky Precertification / Prior Approval Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMembers/providers must contact the Local Plan prior to scheduled inpatient admission or within two business days after emergency admission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior approval requiredInpatient admissions

Prior approval requiredABA services

$100Blue Focus penalty

Kidney/corneaTransplant exceptions

30 daysRTC limit

Prior Approval and Precertification Coverage Criteria

Policy Summary

PayerAnthem

PolicyFEP Kentucky Precertification / Prior Approval Requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMembers/providers must contact the Local Plan prior to scheduled inpatient admission or within two business days after emergency admission.

SourceLink

On This Page

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Prior approval coverage criteria

Services requiring prior approval and the conditions under which prior approval is required, exceptions, and penalties.

ALL of the following

ONE OF: Air ambulance transport (non-emergent)
ONE OF: Applied behavior analysis (ABA) — prior approval required; clinical review for medical necessity and parent/guardian engagement required.
ONE OF: Artificial heart implantation
ONE OF: BRCA / large genomic rearrangement testing (preventive or diagnostic)
ONE OF: Clinical trials for certain blood or marrow stem cell transplants
ONE OF: Gender reassignment surgery
ONE OF: Gene therapy and cellular immunotherapy (e.g., CAR-T, T-cell receptor therapies)
ONE OF: Hospice care (prior approval required except when Medicare Part A is primary)
ONE OF: Organ/tissue transplants (prior approval does not apply for kidney or cornea)
ONE OF: Outpatient IMRT for cancers other than head, neck, breast or prostate and other anal cancer; IMRT for brain cancer requires prior approval (brain cancer is not considered head/neck).
ONE OF: Outpatient surgery for morbid obesity
ONE OF: Surgery to treat morbid obesity

ALL of the following

Prior approval required for the listed Blue Focus outpatient/professional services; if prior approval is not obtained, a $100 penalty is applied to professional and outpatient facility claims (does not apply to prescription drugs).
ONE OF: Gene therapy and cellular immunotherapy
ONE OF: Air ambulance transport (non-emergent)
ONE OF: Applied Behavior Analysis (ABA)
ONE OF: Genetic testing (BRCA, large genomic rearrangements, genetic testing for diagnosis/management)

ALL of the following

Precertification must be obtained prior to admission or the entire admission is denied as non-covered.
Member must be enrolled and participating in case management prior to RTC admission and remain in case management through post-discharge.
Facility must provide a preliminary treatment plan and a discharge plan prior to admission and must be licensed and accredited.
Care must be medically necessary for treatment of a mental health, substance use, or medical condition.
FEP Blue Focus: coverage up to a combined total of 30 days (medical and mental health) of inpatient RTC care for members enrolled and participating in case management when care is medically necessary.

Provider Actions, Precertification Steps, and Penalties

Note

Precertification / Prior Approval Contact

Precertification/Prior Approval Contact: Members or providers must contact the Local Plan prior to a scheduled inpatient admission or within two business days after an emergency inpatient admission. For precertification and prior-approval for outpatient services call 800-860-2156 (8AM - 7PM ET) Monday–Friday or fax 800-732-8318.

Prior Authorization

Inpatient Prior Approval Requirements

Inpatient prior approval is required for all inpatient admissions under Standard, Basic, and Blue Focus except where specifically noted. This includes all inpatient, long-term acute rehab, and obstetric delivery stays beyond the federal-mandated minimum length of stay (including newborn stays beyond the mother’s stay). Emergency admissions require Plan notification no later than two business days after admission. Inpatient admissions for all solid organ and bone marrow/stem cell transplants (including kidney-only transplants) require prior approval.

Inclusive of all Inpatient, Long Term Acute Rehab, and OB delivery stays beyond federal mandate minimum LOS (including newborn stays beyond the mother's stay)
Emergency admissions — Plan notification required no later than 2 business days after admission
Prior approval required for all solid organ and bone marrow/stem cell transplants (including kidney-only)

Prior Authorization

Outpatient Prior Approval List (Standard & Basic)

The following outpatient services require prior approval under Standard and Basic options (consolidated): air ambulance transport (non-emergent); applied behavior analysis (ABA); artificial heart implantation; BRCA and large genomic rearrangement testing; clinical trials for certain blood or marrow stem cell transplants; gender reassignment surgery; gene therapy and cellular immunotherapy (e.g., CAR T and T‑cell receptor therapies); hospice care; organ/tissue transplants (prior approval does not apply for kidney or cornea transplant under Standard/Basic); outpatient IMRT for cancers other than head/neck, breast, prostate and anal cancer (brain cancer requires prior approval); outpatient surgery for morbid obesity; surgeries to treat morbid obesity.

Air ambulance transport (non-emergent)
Applied behavior analysis (ABA) — prior approval required for all ABA therapy; clinical review for medical necessity; parents/guardians must be engaged in treatment plan
BRCA/LGR testing (preventive or diagnostic)
Gene therapy and cellular immunotherapy (e.g., CAR T)
Outpatient IMRT (exceptions noted; IMRT for brain cancer requires prior approval)
Outpatient and surgical treatment of morbid obesity
Clinical trials for certain blood or marrow stem cell transplants
Gender reassignment surgery

Denial Risk

Blue Focus Prior Approval Penalty

Blue Focus outpatient/professional prior approval requirements and penalty: Specific outpatient procedures require prior approval under Blue Focus. If prior approval is not obtained for covered outpatient/professional services (except certain prescription drugs and supplies), a $100 penalty will be applied to the professional and outpatient facility claims once the service is otherwise approved. The $100 penalty does not apply to drugs.

Services requiring prior approval under Blue Focus include, but are not limited to: Gene therapy and cellular immunotherapy; Air ambulance transport (non-emergent); Applied behavior analysis (ABA); Genetic testing (BRCA and LGR, testing for diagnosis/management); Surgical services such as morbid obesity surgery, breast reduction/augmentation not related to cancer, gender reassignment, outpatient surgical correction of congenital anomalies, oral maxillofacial surgeries, orthognathic surgery, many orthopedic and reconstructive procedures, rhinoplasty, septoplasty, varicose vein treatment; Outpatient IMRT; Hospice care; Cardiac and pulmonary rehabilitation; Cochlear implants; Outpatient residential treatment centers; Prosthetic devices (external); Radiology high-technology (MRI, CT, PET) — not related to immediate emergency care; Specialty DME; Transplants (except cornea and kidney); Blood or marrow stem cell transplants; Transplant travel; Prescription drugs and supplies (note: $100 penalty does not apply to drugs)

Prior Authorization

RTC Precertification and Case Management

Residential Treatment Center (RTC) precertification and case management requirements: FEP members must be enrolled and actively participating in case management prior to RTC admission and remain in case management through post-discharge. The facility must provide a preliminary treatment plan and a discharge plan prior to admission. Care must be medically necessary for treatment of a mental health, substance use, or medical condition. Precertification must be obtained prior to admission — lack of precertification will result in the entire admission being denied as non-covered. The RTC must be licensed and accredited. Additional Blue Focus limit: combined total (medical and mental health) of up to 30 days of inpatient RTC care when member is enrolled and participating in case management and care is medically necessary. Basic Option and FEP Blue Focus members must use Preferred facilities when applicable.

Member must be enrolled and participating in case management prior to admission and through post-discharge
Facility must provide preliminary treatment plan and discharge plan prior to admission
Precertification required prior to admission — admission denied as non-covered without precertification
RTC must be licensed and accredited
FEP Blue Focus: up to a combined total of 30 days of inpatient RTC care (medical + mental health) when case managed and medically necessary
Basic Option and FEP Blue Focus members must use Preferred facilities

Definitions and Terms

Precertification (precert)

TermPrecertification (precert)

DefinitionThe contractual requirement for the member to contact the Local Plan where services will be performed before being admitted for inpatient care, or within two business days following admission when the hospital admission is an emergency.

Contact channelsPhone and fax contact information provided in the document for precertification submissions.

Precertification (detail)

Contractual timing requirementMember must contact the Local Plan prior to scheduled inpatient admission or within two business days after an emergency inpatient admission.

ScopeApplies to all inpatient admissions including long term acute rehab and OB deliveries beyond federal minimum LOS.

Notification for emergency admissionsPlan must be notified no later than 2 business days after admission for emergency cases.

Prior approval

DefinitionPrior approval (referred to as prior-approval) is precertification applied to outpatient services.

Usage in documentThe term 'prior-approval' is used to denote precertification requirements for outpatient services under the plan.

Related contact infoProviders/members should use the Local Plan contact channels (phone/fax) listed for precertification/prior approval requests.

OpenPayer

FEP Kentucky Precertification / Prior Approval Requirements

Prior Approval and Precertification Coverage Criteria

Coding and Limits

Provider Actions, Precertification Steps, and Penalties

Definitions and Terms