CurrentAnthemPolicy N/A

Precertification / Prior Approval Requirements

Defines services that require precertification or prior approval for Federal Employee Program (FEP) members and related procedural details; affects members, providers, and Local Plans administering inpatient, outpatient, mental health, autism/ABA, transplant, and specialty services.

Policy Summary

PayerAnthem

PolicyPrecertification / 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 for precertification prior to inpatient admissions or within two business days for emergency admissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior approvalApplied Behavior Analysis (ABA) prior approval

Most transplantsOrgan/tissue transplant prior approval rule

2 business daysEmergency admission notification timing

$100Blue Focus penalty for missed prior approvals

30 daysRTC day limit

Precertification and Coverage Criteria

inv-01: Prior approval and coverage criteria

Covered or subject to prior approval when the following service-specific rules and procedural requirements are met:

ALL of the following

Services requiring prior approval (Standard & Basic / Blue Focus)
- Applied Behavior Analysis (ABA) — prior approval required for all ABA therapy; clinical review required for medical necessity; parents/guardians must be engaged in the treatment plan.
- Air ambulance transport (non-emergent) — prior approval required.
- Gene therapy and cellular immunotherapy (for example, CAR-T and T-cell receptor therapy) — prior approval required.

Policy Summary

PayerAnthem

PolicyPrecertification / 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 for precertification prior to inpatient admissions or within two business days for emergency admissions.

SourceLink

On This Page

Additional Blue Focus-specific prior approval list

Blue Focus requires prior approval for a broader set of outpatient procedures (examples include: gene therapy and cellular immunotherapy; air ambulance transport non-emergent; ABA; genetic testing including BRCA and large genomic rearrangements; specified surgical services such as morbid obesity surgery, breast reduction/augmentation not related to cancer, gender reassignment, oral/maxillofacial and orthognathic surgeries, certain orthopedic and reconstructive surgeries, rhinoplasty, septoplasty, varicose vein treatment).
Blue Focus requires prior approval for high-technology radiology (MRI, CT, PET), specialty DME (e.g., specialty hospital beds, deluxe equipment), cochlear implants, outpatient residential treatment centers, cardiac and pulmonary rehabilitation, prosthetic (external) devices, transplants (except cornea and kidney), blood or marrow stem cell transplants, clinical trials for certain stem cell transplants, transplant travel, and many other listed services.
When prior approval is not obtained under Blue Focus for specified outpatient/professional services and the service is later approved, the Local Plan should apply a $100 penalty to professional and outpatient facility claims (the $100 penalty does not apply to drugs).

Residential Treatment Center (RTC) precertification and limits

Precertification must be obtained prior to RTC admission or the entire admission is denied as non-covered.
Members 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 abuse or medical condition.
FEP Blue Focus: coverage limited to a combined total of 30 inpatient days (medical and mental health) provided and billed by RTCs for members enrolled and participating in case management when medically necessary.<= 30 days

Procedures, Codes, and Limits

Procedures and service categories requiring prior approvalmixed

No explicit CPT/HCPCS/ICD codes provided in document.

RTC day limit (Blue Focus)

RTC day limit (FEP Blue Focus)Combined total of 30 inpatient days (medical and mental health) covered for FEP Blue Focus members enrolled and participating in case management

Eligibility requirementMember must be enrolled and participating in case management prior to RTC admission and remain in case management through post discharge

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

Facility requirementsResidential Treatment Center must be licensed and accredited and provide preliminary treatment and discharge plans prior to admission

Provider Responsibilities and Authorization Workflow

Prior Authorization

Prior Authorization Required — Blue Focus Outpatient/Professional Services

Providers must obtain prior approval for specific services under the Blue Focus contract. When prior approval is not obtained, a $100 penalty will be applied to professional and outpatient facility claims once services have been approved. Contact the plan for outpatient precertification as required.

$100 penalty applies to professional and outpatient facility claims for services not prior-approved (penalty does not apply to prescription drugs).
Prior approval required for the following outpatient/professional services under Blue Focus: Gene Therapy and Cellular Immunotherapy; Air Ambulance Transport (non-emergent); Applied Behavior Analysis (ABA); Genetic Testing (including BRCA, large genomic rearrangements of BRCA1/BRCA2, and genetic testing for diagnosis/management of an existing medical condition); Specified Surgical Services (morbid obesity; breast reduction/augmentation not related to cancer; gender reassignment; outpatient correction of congenital anomalies; oral/maxillofacial surgeries; orthognathic surgery, bone grafts, osteotomies, TMJ surgical management; orthopedic procedures; reconstructive surgery other than breast; rhinoplasty; septoplasty; varicose vein treatment); Outpatient intensity-modulated radiation therapy (IMRT); Hospice care; Cardiac rehabilitation; Cochlear implants; Outpatient Residential Treatment Centers; External prosthetic devices; Pulmonary rehabilitation; High-technology radiology (MRI, CT, PET — when not related to immediate care of medical emergency or accidental injury); Specialty DME (specialty hospital beds, deluxe equipment); Transplants (except cornea and kidney), including blood or marrow stem cell transplants, organ/tissue transplants, transplant travel, and clinical trials for certain blood or marrow stem cell transplants.
For Applied Behavior Analysis (ABA): prior approval is required and clinical review for medical necessity is performed; parents/guardians must be engaged in the treatment plan.

Prior Authorization

ABA Prior Approval and Medical Necessity Review

Applied Behavior Analysis (ABA) requires prior approval under the Blue Focus contract and is subject to medical necessity review. Ensure prior approval is in place before initiating services.

Prior approval required for all ABA therapy and all related services (assessments, evaluations, treatments).
Clinical review required to determine medical necessity.
Parents/guardians must be engaged in the treatment plan.

Key Definitions and Scope Notes

Precertification (contact & timing)

Definition (Precertification)Member must contact the Local Plan before inpatient hospital admission or within two business days following an emergency admission

ScopeApplies to inpatient admissions where precertification is required by the contract

Contact informationPhone: 800-860-2156 (8AM - 7PM ET) Monday-Friday; FAX: 800-732-8318

Inpatient prior approval requirements

Prior approval for extended inpatient staysPrior approval required for inpatient, long term acute rehab, and OB delivery stays beyond the federal mandate minimum length of stay (including newborn stays beyond the mother's stay)

Emergency admissionsEmergency admissions require Plan notification no later than 2 business days after admission

TransplantsPrior approval required for inpatient admits for all solid organ and bone marrow/stem cell transplants (including kidney) unless otherwise specified

Applied Behavior Analysis (ABA) coverage

Coverage for ASDBenefits for ABA and all related services, including assessments, evaluations, and treatments, are included for autism spectrum disorder

Prior approval & reviewPrior approval is required for all ABA therapy and clinical review is required for medical necessity determination

Parental involvementParents/Guardians must be engaged in the treatment plan

ExclusionsABA and related services are excluded for any condition other than an autism spectrum disorder and when provided in or by a school/educational setting or as replacement for educational system responsibilities