FEP Precertification / Prior Approval Requirements (Kentucky)
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Governs precertification and prior approval processes for the Federal Employee Program (FEP) benefit plan in Kentucky, specifying services that require prior approval and contact methods; affects members, providers, and facilities delivering inpatient, outpatient, mental health, transplant, ABA and other listed services.
No material clinical or coverage changes in this revision.
Services Requiring Prior Approval and Coverage Criteria
Prior approval coverage criteria
Services and situations that require prior approval (precertification) or have special coverage rules under the FEP plans for Kentucky.
ALL of the following
- Members/providers must contact the Local Plan before inpatient admission or within two business days after emergency admission (precertification requirement).
See inpatient-specific rules for emergency notification timing.
Inpatient admissions
- Inpatient admissions beyond the federal minimum length of stay require prior approval.
Applies to Standard, Basic, and Blue Focus inpatient admission rules.
- Emergency admissions: notification to the Local Plan must occur no later than 2 business days after the admission.
Failure to notify may affect coverage or trigger precertification rules.
- All inpatient admissions for mental health and substance abuse to an inpatient treatment facility require prior approval based on medical necessity.
Residential Treatment Centers (RTC) have additional requirements (see RTC node).
Transplants
- All solid organ and blood or marrow (bone marrow/stem cell) transplants require prior approval.
Prior approval does not apply for kidney or cornea transplant in some cases (exceptions noted).
Outpatient services list
- Services listed (examples include): gene therapy and cellular immunotherapy (e.g., CAR T), air ambulance transport (non-emergent), Applied Behavior Analysis (ABA), BRCA/LGR genetic testing, hospice care, outpatient IMRT for specified cancers, outpatient and surgical treatment for morbid obesity, many specified surgical categories, certain high-technology radiology (MRI/CT/PET under Blue Focus), specialty DME, prosthetics, cochlear implants, cardiac and pulmonary rehabilitation, transplant-related services and transplant travel, clinical trials for certain transplants.
See Standard/Basic and Blue Focus lists for plan-specific items and exceptions (e.g., IMRT cancer site exceptions; Blue Focus applies $100 penalty when prior approval not obtained for professional/outpatient claims, except prescription drugs).
ABA (Applied Behavior Analysis)
- 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.
ANY of the following
- ABA and related services are excluded when provided for any condition other than an autism spectrum disorder.
- ABA services and related services performed as part of an educational program, provided in or by a school/educational setting, or provided as a replacement for services that are the responsibility of the educational system are excluded.
Residential Treatment Centers (RTC)
- Precertification must be obtained prior to RTC admission; without precertification the entire admission is denied as non-covered.
- FEP 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 specific limit: coverage 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.
Applies to room and board and covered therapy services billed by the facility; Basic Option and Blue Focus members must use Preferred facilities for RTC admissions.
Plan-specific penalties and exceptions
- Blue Focus: If prior approval is not obtained for listed professional and outpatient services, a $100 penalty will be applied to the claim once services are approved; the $100 penalty does not apply to prescription drugs and supplies.
- Hospice: prior approval required except when Medicare Part A is primary (i.e., when Medicare Part A is primary, prior approval is not required).
See hospice entry in outpatient list for plan context.
Providers should consult the applicable plan option (Standard, Basic, or Blue Focus) lists for exact services requiring prior approval and follow Local Plan contact procedures for submitting prior approval requests and for case management enrollment where required.
Coding Notes and Related Limits
| No specific CPT/HCPCS/ICD codes listed in source |
Prior Authorization / Precertification — Provider Responsibilities
Precertification / Prior Approval general rule
Members/providers must contact the Local Plan before inpatient admission or within two business days following an emergency inpatient admission; prior-approval (precertification) is also the requirement for outpatient services.
- Phone: 800-860-2156 (8AM - 7PM ET) Monday-Friday
- FAX: 800-732-8318
Inpatient prior approval requirements
Prior approval is required for all inpatient stays beyond the federal mandate minimum length of stay, for emergency admissions (notification no later than 2 business days after admission), and for all solid organ and bone marrow/stem cell transplants (including kidney-only transplants).
- Applies to Inpatient, Long Term Acute Rehab, and OB delivery stays beyond the 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
- Includes inpatient admits for all solid organ and bone marrow/stem cell transplants (including kidney-only)
Outpatient prior approval list
A range of outpatient services require prior approval under the Standard, Basic, and/or Blue Focus contracts; providers should obtain prior approval for listed services before delivering care.
- Air ambulance transport (non-emergent)
- Applied behavior analysis (ABA)
- Gene therapy and cellular immunotherapy (e.g., CAR-T, T‑cell receptor therapy)
- BRCA/Large genomic rearrangement testing and other specified genetic testing
- Outpatient IMRT for specified cancers (prior approval required for brain and cancers other than head, neck, breast, prostate; see exclusions)
- Hospice care
- Outpatient and surgical services for morbid obesity; certain surgical categories (e.g., gender reassignment, orthognathic, reconstructive, rhinoplasty)
- Radiology high-technology (MRI, CT, PET) and specialty DME under Blue Focus
- Transplants (organ/tissue, blood or marrow stem cell) — prior approval does not apply for kidney or cornea in some Standard/Basic listings; Blue Focus requires prior approval except cornea and kidney
MH/SA authorization rules
All inpatient admissions for mental health and substance abuse require prior approval determined by the Service Benefit Plan definition of medical necessity; Residential Treatment Center admissions require precertification prior to admission.
- RTC admissions: member must be enrolled and participating in case management prior to admission and through post-discharge
- Facility must provide preliminary treatment and discharge plans prior to admission; facility must be licensed and accredited
- Precertification must be obtained prior to RTC admission or the entire admission is denied as non-covered
- FEP Blue Focus RTC coverage limited to a combined total of 30 days (medical and mental health) for members enrolled in case management when medically necessary
ABA prior approval
Prior approval is required for all Applied Behavior Analysis (ABA) therapy, and clinical review is required to determine medical necessity.
- Parents/guardians must be engaged in the treatment plan
Key Terms
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