CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Precertification / Prior Approval Requirements (Federal Employee Program)

Defines prior authorization (precertification) requirements and contact information for the Federal Employee Program (FEP) Service Benefit Plan, including which inpatient and outpatient services require prior approval and special rules for Blue Focus, mental health/substance abuse, and autism/ABA services. Affects members, providers, and Local Plans administering FEP benefits.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyPrecertification / Prior Approval Requirements (Federal Employee Program)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMembers/providers must contact the Local Plan before inpatient admission or within two business days after emergency admission; prior approval phone and fax numbers are provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

800-860-2156Precertification phone (business hours)

800-732-8318Precertification fax

Prior approvalInpatient admissions (notify within 2 business days)

Prior approvalMultiple outpatient services

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Prior approval coverage criteria

Prior approval (precertification) is required as specified below; some services are excluded or limited.

ALL of the following

ALL of the following
- Prior approval is required for all inpatient admissions including Long Term Acute Rehab and OB delivery stays beyond federal minimum LOS; emergency admissions require Plan notification no later than 2 business days after admission.
- All solid organ and bone marrow/stem cell transplants (including kidney-only transplants) require prior approval.
ALL of the following
- Examples of outpatient services requiring prior approval
  - Applied Behavior Analysis (ABA) — prior approval is required for all ABA therapy; parents/guardians must be engaged and clinical review is required for medical necessity.
  - Air ambulance transport (non-emergent).
  - Gene therapy and cellular immunotherapy (e.g., CAR-T and T-cell receptor therapy).
  - BRCA/large genomic rearrangement testing and other specified genetic testing.
  - Outpatient intensity-modulated radiation therapy (IMRT) for specified cancers (approval required for cancers other than head, neck, breast, prostate; brain cancer requires prior approval).
  - Organ/tissue transplants (prior approval does not apply to kidney or cornea transplant).
  - Hospice care; certain surgical and specialty procedures listed under Blue Focus (see Blue Focus section).
- ALL of the following
  - Blue Focus designates numerous procedures that require prior approval (examples include ABA, gene therapy, genetic testing, many surgical procedures, IMRT, imaging such as MRI/CT/PET, specialty DME, transplants except cornea and kidney, and more).
  - When prior approval is not obtained for Blue Focus-specified services, a $100 penalty will be applied to professional and outpatient facility claims once services are approved (the $100 penalty does not apply to drugs).
ALL of the following
- All inpatient admissions for mental health and substance abuse to an inpatient treatment facility require prior approval based on the Service Benefit Plan definition of medical necessity.
- Residential Treatment Centers (RTCs): 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; care must be medically necessary; precertification must be obtained or the admission is denied as non-covered.
- FEP Blue Focus RTC limit: up to a combined total of 30 days (medical and mental health) of inpatient RTC care is covered for members enrolled and participating in case management when care is medically necessary; RTC must be licensed and accredited; Basic Option and Blue Focus members must use Preferred facilities.
ALL of the following
- ABA benefits are included for autism spectrum disorder in 2021 and prior approval is required for all ABA therapy.
- ABA and related services are excluded when provided for any condition other than an autism spectrum disorder, when performed as part of an educational program or provided in/by a school/educational setting, or when they replace services that are the responsibility of the educational system.

Operational note: Members/providers must contact the Local Plan before inpatient admission or, for emergency admissions, notify the Plan no later than two business days after admission; precertification phone and fax numbers are provided in the Plan materials.

Services and Coding Requiring Prior Approval

Services requiring prior approval (no code list)mixed

List of services requiring prior approval (examples: Applied behavior analysis; Air ambulance transport (non-emergent); Gene therapy and cellular immunotherapy; Organ/tissue transplants (except kidney or cornea); Hospice care; Outpatient IMRT for specified cancers; Surgical services including gender reassignment, morbid obesity surgery, breast reduction/augmentation not related to cancer; Clinical trials for certain blood or marrow stem cell transplants; Genetic testing including BRCA and large genomic rearrangements; Prosthetic devices; Cochlear implants; Specialty hospital beds and DME; Radiology high technology such as MRI, CT, PET; Transplant travel; Outpatient residential treatment centers; Pulmonary and cardiac rehabilitation; Varicose vein treatment; Orthognathic and oral maxillofacial surgeries; Reconstructive surgery (other than breast); Rhinoplasty; Septoplasty; Orthopedic procedures; Note: specific CPT/HCPCS/ICD-10 codes are not provided in the source.

RTC combined inpatient days (Blue Focus)

Combined RTC inpatient days (Blue Focus)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

Case management requirementMembers 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

Medical necessity and documentationCare must be medically necessary and facility must provide a preliminary treatment plan and a discharge plan prior to admission

Provider Responsibilities and Notification Timing

Prior Authorization

Precertification contacts and timing

Members and providers must contact the Local Plan where services will be performed before inpatient admission, or notify the Plan within two business days following an emergency inpatient admission. For outpatient precertification, prior-approval phone and fax are: Phone 800-860-2156 (8AM–7PM ET, Mon–Fri) and Fax 800-732-8318.

Contact Local Plan prior to scheduled inpatient admission.
Notify Local Plan no later than two business days after an emergency admission.
Use phone 800-860-2156 (8AM–7PM ET) or fax 800-732-8318 for outpatient prior-approval requests.

Prior Authorization

Services requiring prior approval and Blue Focus penalty

Prior approval is required for all inpatient admissions (including long-term acute rehab and OB stays beyond federal minimums) and for specified outpatient services under Standard/Basic and Blue Focus; under Blue Focus, a $100 penalty applies to professional and outpatient facility claims when prior approval is not obtained (drugs exempt).

Inpatient admissions inclusive of all inpatient care, LTAC, and OB deliveries beyond federal mandated LOS require prior approval.
Blue Focus requires prior approval for a long list of outpatient services (examples: gene therapy, ABA, air ambulance, genetic testing, IMRT, many surgeries, imaging, transplants).
$100 penalty applied to professional and outpatient facility claims once services are approved if prior approval was not obtained (prescription drugs exempt).

Prior Authorization

Behavioral health prior approval rules

All inpatient admissions for mental health and substance abuse require prior approval based on the Service Benefit Plan's medical necessity criteria; RTC admissions require precertification and members must be enrolled and participating in case management before admission and through post-discharge.

Prior approval is required for any inpatient MH/SA admission per medical necessity.
Residential Treatment Centers: member must be enrolled in case management prior to admission and remain in case management post-discharge; facility must provide preliminary treatment and discharge plans; precertification must be obtained or the admission is denied as non-covered.
FEP Blue Focus: up to a combined total of 30 days (medical and mental health) of inpatient RTC care when member is enrolled and participating in case management and care is medically necessary.

Definitions and Key Terms

Precertification / Prior approval

DefinitionPrecertification (Prior approval) is the contractual requirement for the member to contact the Local Plan where services will be performed before inpatient admission or for outpatient services to obtain prior approval

How to requestContact the Local Plan by phone or fax using the precertification contact information provided (phone: 800-860-2156; fax: 800-732-8318)

Timing for inpatientFor non-emergency inpatient admissions, contact the Local Plan before admission; for emergency admissions, notify the Plan within two business days after admission

Emergency admission notification

Timing requirementFor emergency hospital admissions, the Plan must be notified no later than two business days after admission

Non-emergency inpatient admissionsMembers/providers must contact the Local Plan before inpatient admission

Consequence of not notifyingFailure to obtain precertification for inpatient admissions can result in denial of the admission as non-covered (per related precertification rules)

OpenPayer

Precertification / Prior Approval Requirements (Federal Employee Program)

Prior Approval / Precertification Coverage Criteria

Services and Coding Requiring Prior Approval

Provider Responsibilities and Notification Timing

Definitions and Key Terms