CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Precertification / Prior Approval Requirements (FEP Blue — California)

Governs prior authorization and precertification requirements for Federal Employee Program (FEP) Blue benefit plans in California, specifying which inpatient, outpatient and specialty services require prior approval and contact details; applies to members and providers using the Local Plan.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPrecertification / Prior Approval Requirements (FEP Blue — California)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification prior to inpatient admission or notify the plan within two business days for emergency admissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

800-860-2156Prior approval phone

800-732-8318Prior approval fax

800-424-4011MHSA prior approval

844-269-0538ABA team phone

Prior approval requiredABA coverage

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1/30/2021Last Updated

Prior Approval Coverage Criteria

Prior approval coverage criteria

Covered when the specified prior-approval requirements are met. Emergency inpatient admissions require plan notification within 2 business days. Failure to obtain required precertification/prior approval may result in denial or penalties as noted.

Outpatient services requiring prior approval (Standard & Basic)

Air ambulance transport (non-emergent)
Applied behavior analysis (ABA)
Breast reduction or augmentation not related to cancer (Blue Focus requirement/see Blue Focus section)
Artificial heart implantation
BRCA/Large genomic rearrangement testing and certain genetic testing
Gender reassignment surgery
Clinical trials for certain blood or marrow stem cell transplants
Gene therapy and cellular immunotherapy (e.g., CAR-T, T-cell receptor therapy)
Organ/tissue transplants (Prior approval does NOT apply for kidney or cornea)

Blue Focus specific outpatient prior-approval list

Gene therapy and cellular immunotherapy
Applied Behavior Analysis (ABA)
Air ambulance transport (non-emergent)
Genetic testing including BRCA and large genomic rearrangements
Surgical services including outpatient surgery for morbid obesity, reconstructive procedures, orthognathic and oral/maxillofacial surgeries
Outpatient intensity-modulated radiation therapy (IMRT)

Residential Treatment Center (RTC) admissions

Facility must provide a preliminary treatment plan and a discharge plan prior to admission
Precertification must be obtained prior to admission or the entire admission is denied as non-covered
Care must be medically necessary and the RTC must be licensed and accredited
FEP Blue Focus: combined total (medical + mental health) up to 30 days of inpatient RTC care when member is enrolled and participating in case management

Applied Behavior Analysis (ABA)

ABA and related services are excluded when provided for conditions other than autism spectrum disorder, when provided as part of an educational program or in a school/educational setting, or when they replace services that are the responsibility of the educational system

Exceptions / notes

Organ/tissue transplants: prior approval does NOT apply for kidney or cornea transplants
Hospice care: prior approval required except when Medicare Part A is primary
Sleep studies: prior approval varies by primary payer and setting (e.g., studies performed outside the home noted)

Coding and Special Limits

Coding referencesmixed

No CPT/HCPCS/ICD codes specified in document.

inv-03: FEP Blue Focus RTC inpatient days — Combined total up to 30 days (medical + mental health) when enrolled and in case management

ScopeFEP Blue Focus RTC inpatient days apply to members enrolled and participating in case management through the Local Plan.

Combined limitUp to a combined total of 30 days of inpatient care (medical + mental health) provided and billed by a Residential Treatment Center (RTC).

Eligibility conditionCare must be medically necessary for treatment of a medical, mental health, and/or substance use disorder.

Precertification requirementPrecertification must be obtained prior to admission or the entire admission is denied as non-covered.

Facility requirementsThe Residential Treatment Center must be licensed and accredited and provide a preliminary treatment plan and a discharge plan prior to admission.

Precertification, Prior-Approval & Provider Responsibilities

Prior Authorization

Precertification / Prior-approval contact and timing

Precertification (precert) is a contractual requirement. For inpatient admissions, the Local Plan where services will be performed must be contacted before a hospital admission for inpatient care, or within two business days after an emergency admission. For outpatient services that require precertification/prior-approval, providers must contact the plan prior to the service.

Precertification phone: 800-860-2156 (8AM–7PM ET) Monday–Friday
Precertification fax: 800-732-8318

Prior Authorization

Blue Focus outpatient prior approval list and penalty

Under the Blue Focus contract a specific list of outpatient procedures and services require prior approval. If prior approval is not obtained for these outpatient professional and facility services, an S100 penalty will be applied to the claims (note: the S100 penalty does not apply to prescription drugs). Providers must obtain prior approval before performing these outpatient services to avoid the penalty.

Gene therapy and cellular immunotherapy

Key Definitions

inv-07: Precertification — Precertification

Definition - PrecertificationContractual requirement for the member to contact the Local Plan before inpatient hospital admission or within two business days following an emergency admission.

TimingBefore admission for scheduled inpatient care, or within two business days after an emergency hospital admission.

Action requiredMember (or provider on member's behalf) must contact the Local Plan to obtain precertification.

inv-08: Prior-approval — Prior-approval (precertification for outpatient services)

Definition - Prior-approvalPrecertification specifically for outpatient services; providers must obtain prior-approval before performing specified outpatient procedures.

Contact information

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPrecertification / Prior Approval Requirements (FEP Blue — California)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification prior to inpatient admission or notify the plan within two business days for emergency admissions.

SourceLink

On This Page

Specialty imaging (MRI, CT, PET) and radiology high-technology

Prosthetic devices (external), specialty hospital beds, specialty DME

Transplants (except cornea and kidney) and blood or marrow stem cell transplants

Outpatient Residential Treatment Centers and hospice care

Applied Behavior Analysis (ABA)

Air ambulance transport (non-emergent)

Genetic testing (including BRCA and large genomic rearrangements of BRCA1/BRCA2) and genetic testing for diagnosis/management of an existing medical condition

Surgical services (including outpatient surgical correction of congenital anomalies, orthognathic surgery, oral/maxillofacial surgery, orthopedic procedures, rhinoplasty, septoplasty)

Morbid obesity surgery and gender reassignment

Breast reduction or augmentation not related to cancer; reconstructive surgery for conditions other than breast surgery

Outpatient intensity-modulated radiation therapy (IMRT)

Varicose vein treatment

Cardiac rehabilitation; pulmonary rehabilitation

Cochlear implants; prosthetic devices (external)

Outpatient residential treatment centers

MRI; CT scans; PET scans; radiology high-technology

Specialty hospital beds; specialty DME; deluxe equipment

Blood or marrow stem cell transplants; organ/tissue transplants (except cornea and kidney) and related clinical trials, transplant travel

Prescription drugs and supplies (S100 penalty does not apply to drugs)

Note: Prior approval requirement does not apply when services are related to immediate care of a medical emergency or accidental injury

Phone for prior approval (outpatient precertification): 800-860-2156 (8AM-7PM ET, Mon-Fri).

FaxPrior approval fax for outpatient precertification: 800-732-8318.