Precertification / Prior Approval Requirements (Federal Employee Program)
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Governs when members must obtain precertification or prior approval from the Local Plan for inpatient admissions, outpatient procedures, specialty services (e.g., transplants, gene therapy, ABA), and certain mental health or residential treatment services for Blue Cross Blue Shield - Maine Federal Employee Program members.
No material clinical or coverage changes in this revision.
Prior Approval and Coverage Criteria
Prior Approval and Coverage Criteria
Services and situations that require prior approval or have coverage restrictions:
Outpatient services requiring prior approval
- Air ambulance transport (non-emergent).
- 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. Benefits for ABA are excluded for conditions other than autism spectrum disorder and when provided as part of an educational program or in a school setting.
- Artificial heart implantation.
- BRCA and large genomic rearrangement (LGR) testing of BRCA1/BRCA2 and other specified genetic testing.
- Gene therapy and cellular immunotherapy (for example, CAR T and T-cell receptor therapies).
- Hospice care.
- Organ/tissue transplants (prior approval does not apply for kidney or cornea transplants).
- Outpatient intensity-modulated radiation therapy (IMRT) for cancers other than head, neck, breast, prostate and other anal cancer (brain cancer is considered not head/neck and requires prior approval).
- Outpatient surgery for morbid obesity and surgical treatment of morbid obesity.
- Outpatient surgical correction of accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth; outpatient surgical correction of congenital anomalies; certain specified surgical and reconstructive procedures (see Blue Focus list).
- Certain prescription drugs and supplies and select diagnostic services (e.g., sleep studies performed outside the home).
Coding — Codes and Status
| No codes listed |
Provider Actions and Prior Authorization Procedures
When to Contact the Local Plan and Prior-approval Timing
Members must contact the Local Plan before a hospital inpatient admission or within two business days following an emergency admission. Prior-approval is the precertification process for outpatient services. Prior-approval phone: 800-860-2156 (8AM - 7PM ET) Monday-Friday; Fax: 800-732-8318.
Services That Require Prior Approval
Certain inpatient admissions and numerous outpatient procedures require prior approval. Emergency inpatient admissions require Plan notification no later than two business days after admission.
- Inpatient admissions (all inpatient, long-term acute rehab, and OB delivery stays beyond the federal minimum LOS; includes newborn stays beyond the mother’s stay)
- Inpatient admits for ALL solid organ and bone marrow/stem cell transplants (including kidney-only transplants)
- Emergency admissions (Plan notification within 2 business days)
- Outpatient services including non-emergent air ambulance, applied behavior analysis, artificial heart implantation, gene therapy/cellular immunotherapy, BRCA/LGR testing, hospice care, IMRT for specified cancers, outpatient surgery for morbid obesity, certain surgical corrections, sleep studies outside the home, and other listed procedures
- Blue Focus-specific outpatient list (e.g., gene therapy, cochlear implants, outpatient RTC, specialty DME, transplants except cornea/kidney); Blue Focus applies a $100 penalty on professional and outpatient facility claims when required prior approval is not obtained (drugs excluded)
Behavioral Health Inpatient Prior Approval (MHSA)
All inpatient admissions for mental health and substance abuse require prior approval and are evaluated based on the Service Benefit Plan description of Medical Necessity. For MHSA phone contact: 800-424-4011 (8AM - 5PM ET) Monday–Friday; Fax: 866-793-0469.
RTC Precertification Required — Denial Risk if Not Obtained
Precertification must be obtained prior to admission to a Residential Treatment Center (RTC); failure to obtain precertification results in the entire admission being 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
- Facility must be licensed and accredited
- Care must be medically necessary for the treatment of a mental health, substance abuse, or medical condition
Applied Behavior Analysis — Prior Approval and Exclusions
Prior approval is required for all Applied Behavior Analysis (ABA) therapy and related services; a clinical review is performed to determine medical necessity. Parents/guardians must be engaged in the treatment plan. ABA benefits are excluded for conditions other than autism spectrum disorder and when ABA services are provided as part of an educational program or in a school/educational setting.
- Prior approval required for all ABA therapy, including assessments, evaluations, and treatments
- Clinical review required for medical necessity determination
- Parents/Guardians must be engaged in the treatment plan
- Exclusions: ABA and related services for any condition other than an autism spectrum disorder; ABA services provided as part of an educational program or provided in/by a school or as a replacement for educational system responsibilities
Key Definitions
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