Precertification / Prior Approval Requirements
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Governs prior authorization (precertification/prior approval) requirements for inpatient and outpatient services under the Blue Cross Blue Shield Federal Employee Program (Service Benefit Plan) and related contract variations (Standard, Basic, Blue Focus). Affects members, providers, and Local Plans performing or arranging services.
No material clinical or coverage changes in this revision.
Prior Approval and Coverage Criteria
Prior Approval / Coverage Criteria
Services that require prior approval or have coverage conditions:
ALL of the following
- Prior approval required for inpatient stays beyond the federal-mandated minimum length of stay, including long-term acute rehab and obstetric delivery stays (including newborn stays beyond the mother's stay).
- Emergency admissions: Local Plan notification required no later than 2 business days after admission.
- All inpatient admissions for solid organ and bone marrow/stem cell transplants require prior approval (including kidney-only transplants).
ALL of the following
ANY of the following
- Air ambulance transport (non-emergent).
- Applied behavior analysis (ABA).
- Artificial heart implantation.
- BRCA/LGR genetic testing (preventive or diagnostic).
- Clinical trials for certain blood or marrow stem cell transplants.
- Gender reassignment surgery (see GRS-CS document).
- Gene therapy and cellular immunotherapy (e.g., CAR-T, T-cell receptor therapy).
- Hospice care.
- Organ/tissue transplants (prior approval does not apply for kidney or cornea transplant).
- Outpatient IMRT for cancers other than head, neck, breast or prostate and other anal cancer (brain cancer requires prior approval).
- Outpatient surgery for morbid obesity.
ALL of the following
ANY of the following
- Gene therapy and cellular immunotherapy.
- Air ambulance transport (non-emergent).
- Applied Behavior Analysis (ABA).
- Genetic testing (BRCA and large genomic rearrangements; testing for diagnosis/management).
- Specified surgical services (morbid obesity, breast reduction/augmentation not related to cancer, gender reassignment, outpatient correction of congenital anomalies, oral maxillofacial surgeries, orthognathic surgery, certain orthopedic procedures, reconstructive surgery other than breast, rhinoplasty, septoplasty, varicose vein treatment).
- Outpatient IMRT.
- Hospice care.
- Cardiac rehabilitation, cochlear implants, outpatient RTC, prosthetic devices (external), pulmonary rehabilitation.
- High-technology radiology (MRI, CT, PET).
- Specialty DME (specialty hospital beds, deluxe equipment).
- Transplants (except cornea and kidney) and blood or marrow stem cell transplants, including transplant travel and clinical trials for certain transplants.
- When prior approval is not obtained, a $100 penalty will be applied to professional and outpatient facility claims once services have been approved (penalty does not apply to prescription drugs and supplies).
Blue Focus enforcement
ALL of the following
- All inpatient mental health and substance abuse admissions require prior approval based on medical necessity.
- Precertification must be obtained prior to RTC admission or 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 preliminary treatment and discharge plans; RTC must be licensed and accredited.
- FEP Blue Focus: coverage up to a combined total of 30 days of inpatient RTC care (medical and mental health) for members enrolled and participating in case management when care is medically necessary.
ALL of the following
- 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.
Exclusions
- ABA and related services for any condition other than an autism spectrum disorder are excluded.
- ABA services provided as part of an educational program, in a school/educational setting, or as a replacement for services that are the responsibility of the educational system are excluded.
ALL of the following
- Prior approval is required for organ/tissue transplants and blood or marrow stem cell transplants, except prior approval does not apply for kidney or cornea transplants (document notes kidney-only transplants are included for inpatient transplant prior approval in some contexts).
- Clinical trials for certain blood or marrow stem cell transplants require prior approval.
Codes, Limits, and Coding Notes
| No explicit CPT/HCPCS/ICD-10 codes provided in document. |
Precertification, Prior Approval & Provider Responsibilities
Precertification / Prior Approval Overview
Precertification (precert) must be obtained before inpatient admission. If the admission is an emergency, the Local Plan must be contacted no later than two business days after admission. Prior approval is required for outpatient services as specified by contract.
- Precertification before inpatient admission or within two business days after emergency admission.
- Prior approval applies to outpatient services (percontract Prior-approval definition).
Inpatient Admissions Requiring Prior Approval
Prior approval is required for inpatient stays that exceed the federal-mandated minimum length of stay (including long-term acute rehab and OB delivery stays and newborn stays beyond the mother's stay). Emergency admissions require notification to the Plan no later than two business days after admission. All inpatient admits for solid organ and bone marrow/stem cell transplants (including kidney-only) require prior approval.
- Inclusive of all 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.
- Inpatient admits for all solid organ and bone marrow/stem cell transplants (including kidney only) require prior approval.
Outpatient Services Requiring Prior Approval
A range of outpatient services require prior approval under Standard/Basic and under Blue Focus contracts. The Blue Focus contract includes a $100 penalty applied to professional and outpatient facility claims when prior approval is not obtained (this penalty does not apply to drugs).
- Standard & Basic: examples include non-emergent air ambulance transport, applied behavior analysis (ABA), gene therapy/CAR-T, hospice, certain genetic testing (BRCA/LGR), outpatient IMRT for specified cancers, organ/tissue transplants (prior approval does not apply for kidney or cornea), outpatient morbid obesity surgery.
- Blue Focus: includes gene therapy/cellular immunotherapy, non-emergent air ambulance, ABA, genetic testing (BRCA and LGR), numerous specified surgical services, outpatient IMRT, hospice, cardiac rehabilitation, cochlear implants, outpatient RTCs, specialty DME, most transplants (except cornea and kidney), transplant travel, and more; $100 penalty applies to professional and outpatient facility claims when prior approval not obtained (not applicable to drugs).
ABA Prior Approval
Prior approval is required for all Applied Behavior Analysis (ABA) therapy and related services. ABA services are subject to clinical review to determine medical necessity.
- Prior approval required for all ABA therapy, including assessments, evaluations, and treatments.
- Clinical review is required to determine medical necessity.
- Parents/guardians must be engaged in the treatment plan (per ABA requirements).
Behavioral Health / RTC Prior Approval
All inpatient admissions for mental health and substance abuse require prior approval based on Medical Necessity. Residential Treatment Center (RTC) admissions must have precertification prior to admission or the entire admission will be denied as non-covered; additional RTC rules apply for FEP Blue Focus.
- Precertification must be obtained prior to RTC admission or 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; care must be medically necessary.
- FEP Blue Focus: combined total coverage limit of 30 days of inpatient RTC care for members enrolled and participating in case management when care is medically necessary.
Key Definitions
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