CurrentAnthemPolicy N/A

Precertification / Prior Approval Requirements (FEP Service Benefit Plan)

Governance of precertification and prior approval requirements for inpatient and outpatient services under the Federal Employee Program (FEP) Service Benefit Plan, including Blue Focus, Standard, and Basic options; affects providers, members, and Local Plans where services are performed.

Policy Summary

PayerAnthem

PolicyPrecertification / Prior Approval Requirements (FEP Service Benefit Plan)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification prior to inpatient admission or within two business days after an emergency admission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/30/2021last updated

800-860-2156precert phone

800-424-4011MHSA phone

844-269-0538ABA team

Prior Approval Coverage Criteria and Exceptions

Emergency admissions: Plan must be notified no later than 2 business days after admission.

All solid organ and blood or marrow (bone marrow/stem cell) transplants: prior approval required (Note: prior approval does not apply for kidney or cornea transplants in outpatient listing).

Outpatient services requiring prior approval for Standard & Basic options (non-exhaustive list): air ambulance transport (non-emergent); applied behavior analysis; artificial heart implantation; BRCA/LGR testing; certain clinical trials for blood or marrow stem cell transplants; gender reassignment surgery; gene therapy and cellular immunotherapy (e.g., CAR-T); hospice care; outpatient IMRT for specified cancers and certain exceptions; outpatient surgery for morbid obesity; and other listed surgical services.

Blue Focus outpatient services requiring prior approval (non-exhaustive list) and $100 penalty when prior approval is not obtained for professional/outpatient facility claims once services have been approved (drugs excluded): gene therapy and cellular immunotherapy; air ambulance (non-emergent); ABA; genetic testing (BRCA and large genomic rearrangements and other genetic testing for diagnosis/management); specified surgical services (morbid obesity surgery, breast reduction/augmentation not for cancer, gender reassignment, oral/maxillofacial, orthognathic, certain orthopedic and reconstructive procedures, rhinoplasty, septoplasty, varicose vein treatment); outpatient IMRT; hospice; cardiac and pulmonary rehabilitation; cochlear implants; outpatient residential treatment centers; specialty DME and prosthetics; radiology high-technology (MRI, CT, PET); transplants (except cornea and kidney); transplant travel; and prescription drugs and supplies (penalty does not apply to drugs).

Applied Behavior Analysis (ABA): prior approval required for all ABA therapy; clinical review required for medical necessity determination; parents/guardians must be engaged in the treatment plan.

ABA exclusions: ABA and related services are excluded when provided for any condition other than an autism spectrum disorder or when provided as part of an educational program, in or by a school/educational setting, or as a replacement for services that are the responsibility of the educational system.

Residential Treatment Centers (RTC): precertification must be obtained prior to admission or the entire admission is denied as non-covered. Additional requirements: member must be enrolled and participating in case management prior to RTC admission and remain in case management through post-discharge; facility must provide preliminary treatment and discharge plans prior to admission; care must be medically necessary; facility must be licensed and accredited. FEP Blue Focus limit: up to a combined total of 30 days (medical and mental health) of inpatient care provided and billed by an RTC for members enrolled and participating in case management when medically necessary.

Inpatient mental health and substance abuse admissions: require prior approval based on the Service Benefit Plan description of Medical Necessity.

Billing/penalty guidance for Blue Focus: when prior approval is not obtained for specified outpatient/professional services, a $100 penalty will be applied once services have been approved (this penalty does not apply to drugs).

Codes and Limits

Codes not specifiedmixed

No explicit CPT/HCPCS/ICD-10 or other codes provided in document.

RTC (Blue Focus) - inpatient day limit and requirements

RTC inpatient day limit (Blue Focus)FEP Blue Focus covers up to a combined total of 30 days (medical and mental health) of inpatient care provided and billed by an RTC when the member is enrolled and participating in case management and care is medically necessary.

Case management requirementMembers must be enrolled and participating in case management prior to RTC admission and remain in case management through post discharge.

Medical necessityCare must be medically necessary for treatment of a medical, mental health, and/or substance use disorder for coverage to apply.

Licensing/accreditationThe Residential Treatment Center must be licensed and accredited to bill for covered services.

Precertification timingPrecertification must be obtained prior to admission or the entire admission is denied as non-covered.

Precertification, Prior Approval and Provider Requirements

Prior Authorization

Precertification / Prior Approval Contact and Timing

Precertification for inpatient admissions and prior approval for outpatient services is required. Members or providers must contact the plan for precertification before inpatient admission or within two business days following an emergency admission. For outpatient prior-approval, contact the plan at Phone: 800-860-2156 (8AM - 7PM ET) Monday-Friday or FAX: 800-732-8318.

Precertification required before non-emergent inpatient admission or within 2 business days after emergency admission.
Prior approval required for outpatient services (precertification = prior-approval for outpatient).
Contact: Phone 800-860-2156 (8AM - 7PM ET) Mon-Fri; Fax 800-732-8318.

Prior Authorization

Services Requiring Prior Approval

The following inpatient and outpatient services require prior approval. Providers should obtain prior approval before scheduling/performing these services to avoid penalties or denial of coverage.

Inpatient: all inpatient stays (including Long Term Acute Rehab and OB delivery stays beyond federal-mandated minimum length of stay, including newborn stays beyond the mothers stay); emergency admissions (notify Plan no later than 2 business days after admission); all solid organ and bone marrow/stem cell transplants (including kidney-only transplants).
Inpatient mental health and substance abuse admissions to inpatient treatment facilities require prior approval per Medical Necessity.
Outpatient (Standard & Basic): air ambulance transport (non-emergent); applied behavior analysis (ABA) — prior approval required and clinical review for medical necessity; artificial heart implantation; BRCA/LGR genetic testing; clinical trials for certain blood or marrow stem cell transplants; gender reassignment surgery; gene therapy and cellular immunotherapy (e.g., CAR T, T-cell receptor therapy); hospice care; organ/tissue transplants (prior approval does not apply to kidney or cornea transplant); outpatient intensity-modulated radiation therapy (IMRT) for specified cancers (including brain cancer); outpatient surgery for morbid obesity; surgery to treat morbid obesity.
Outpatient (Blue Focus): gene therapy and cellular immunotherapy; air ambulance (non-emergent); ABA; genetic testing (BRCA, large genomic rearrangements, diagnostic/management testing); numerous surgical services (morbid obesity, breast reduction/augmentation not related to cancer, gender reassignment, outpatient correction of congenital anomalies, oral/maxillofacial, orthognathic/TMJ, orthopedic, reconstructive other than breast, rhinoplasty, septoplasty, varicose vein treatment); outpatient IMRT; hospice; cardiac and pulmonary rehabilitation; cochlear implants; outpatient residential treatment centers; prosthetic devices (external); radiology high-technology (MRI, CT, PET) not related to immediate care of emergency/accident; specialty DME (specialty hospital beds, deluxe equipment); transplants (except cornea and kidney) including blood or marrow stem cell transplants; clinical trials for certain stem cell transplants; transplant travel; certain prescription drugs and supplies (note: $100 penalty applies to professional and outpatient facility claims when prior approval not obtained under Blue Focus; penalty does not apply to drugs).

Denial Risk

RTC Precertification and Enrollment Requirements

Residential Treatment Center (RTC) admissions require precertification and enrollment in case management prior to admission. If precertification is not obtained, the entire RTC admission will be denied as non-covered.

FEP members must be enrolled and actively 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.
Care must be medically necessary for treatment of a mental health, substance abuse, or medical condition.
The Residential Treatment Center must be licensed and accredited.
FEP Blue Focus: coverage limited to up to a combined total of 30 days of inpatient care provided and billed by an RTC when member is enrolled and participating in case management through the Local Plan; room and board and covered therapy services billed by the facility are included as described.
Basic Option and FEP Blue Focus members must use Preferred facilities; benefits are available for RTC inpatient admission if covered by Medicare.

Key Terms and Requirements

Precertification — definition and contact timing

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

Contact timingBefore inpatient admission or within two business days after an emergency admission.

Who must contactThe member must contact the Local Plan where services will be performed.

Local Plan contact infoPhone: 800-860-2156 (8AM - 7PM ET) Monday-Friday; FAX: 800-732-8318.

Prior-approval — definition

DefinitionPrior-approval denotes the precertification requirement for outpatient services.

Relation to precertificationPrior-approval is the term used when precertification applies to outpatient (non-inpatient) services.

Provider actionObtain prior-approval (precertification) for outpatient services as required by the plan before scheduling/providing the service.