Precertification / Prior Approval Process

Precertification (precert) is a contractual requirement. Providers must contact the Local Plan where services will be performed before inpatient hospital admissions, or within two business days following the admission when the hospital admission is an emergency. For outpatient services, prior-approval (precertification) is also required.

• Phone: 800-860-2156 (8AM - 7PM ET) Monday-Friday
• FAX: 800-732-8318

Inpatient and MHSA Prior Approval Requirements

All inpatient admissions for mental health and substance abuse (MHSA) to an inpatient treatment facility require prior approval based on the Service Benefit Plan description of Medical Necessity. This includes emergency admissions (the Plan must be notified no later than 2 business days after admission). Prior approval is required for inpatient stays (including long-term acute rehab and obstetric delivery stays beyond federally mandated minimum length of stay) and for all solid organ and bone marrow/stem cell transplants.

• Plan notification required no later than 2 business days after emergency admission
• Prior approval based on Medical Necessity per Service Benefit Plan

Blue Focus Prior Approval and Penalty

Under the Blue Focus contract, specific outpatient and professional services require prior approval. If prior approval is not obtained, a $100 penalty will be applied to professional and outpatient facility claims after services have been approved. (This penalty does not apply to prescription drugs and supplies.)

• Penalty: $100 for failure to obtain Blue Focus prior approval on professional and outpatient facility claims (exceptions: prescription drugs and supplies)
• Examples of services requiring prior approval include: Gene therapy and cellular immunotherapy; Air ambulance (non-emergent); Applied Behavior Analysis (ABA); Genetic testing (e.g., BRCA and large genomic rearrangements, genetic testing for diagnosis/management); Numerous surgical services (e.g., morbid obesity surgery, breast reduction/augmentation not cancer-related, gender reassignment, orthognathic and oral maxillofacial surgeries, rhinoplasty, septoplasty, varicose vein treatment, certain orthopedic and reconstructive procedures); Outpatient IMRT; Hospice care; Cardiac and pulmonary rehabilitation; Cochlear implants; Outpatient residential treatment centers; External prosthetic devices; High-technology radiology (MRI, CT, PET) not related to immediate care of emergency or accidental injury; Specialty DME (specialty hospital beds, deluxe equipment); Transplants (except cornea and kidney) and blood/marrow stem cell transplants; Transplant travel; Certain clinical trials; Note: prescription drugs and supplies excluded from penalty