CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Precertification / Prior Approval Requirements (FEP)

Defines precertification and prior approval requirements for Federal Employee Program (FEP) Blue Cross Blue Shield services, listing inpatient and outpatient services that require prior approval and describing caller/contact information and special rules (e.g., Blue Focus). Applies to members and providers under the FEP plans.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPrecertification / Prior Approval Requirements (FEP)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMembers or providers must contact the Local Plan before inpatient admission or within two business days after an emergency admission to obtain precertification.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

800-860-2156Precert phone

800-732-8318Precert fax

Prior approval requiredABA stance

$100Blue Focus penalty

Prior Approval and Coverage Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior approval coverage criteria and rules

Prior approval (precertification) is required for the services and situations listed below. Where noted, exceptions, penalties, enrollment or case‑management requirements apply.

ALL of the following

Inpatient admissions
- Inpatient, long term acute rehab, and obstetrical delivery stays beyond the federal minimum length of stay (including newborn stays beyond the mother’s stay) require precertification.precertification required
  Applies to Standard, Basic and Blue Focus plans.
- Emergency inpatient admissions: the Plan must be notified no later than 2 business days after admission.notification within 2 business days
Transplants
- Inpatient admissions for all solid organ and blood or marrow (bone marrow/stem cell) transplants require prior approval.
- Prior approval does not apply for kidney or cornea transplant (these are exceptions).
Residential Treatment Centers (RTC)
- Precertification must be obtained prior to admission or the entire admission will be 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, be licensed and accredited, and care must be medically necessary for treatment of a mental health, substance use, or medical condition.
Applied Behavior Analysis (ABA)
- Prior approval is required for all ABA therapy and related services (assessments, evaluations, treatments).
- Clinical review is required for a medical necessity determination and parents/guardians must be engaged in the treatment plan.
- ABA benefits are excluded for any condition other than an autism spectrum disorder, and are excluded when provided as part of an educational program, in a school/educational setting, or as a replacement for services the educational system is responsible for.
Outpatient services requiring prior approval
- Outpatient intensity-modulated radiation therapy (IMRT) requires prior approval for cancers other than head, neck, breast, prostate, or anal cancer; IMRT for brain cancer requires prior approval (brain cancer is not considered head/neck).
- Outpatient surgery for morbid obesity and surgery to treat morbid obesity require prior approval.
- Gene therapy and cellular immunotherapy (for example CAR-T and T-cell receptor therapy) require prior approval.
- Air ambulance transport (non-emergent) requires prior approval.
- Artificial heart implantation requires prior approval.
- BRCA/large genomic rearrangement testing and other genetic testing as specified require prior approval.
Blue Focus specific prior-approval items and penalties
- Under Blue Focus, specified surgical and radiology procedures and other services require prior approval; when prior approval is not obtained, a $100 penalty may be applied to professional and outpatient facility claims (penalty does not apply to prescription drugs).
- Examples of services requiring prior approval under Blue Focus include: gene therapy and cellular immunotherapy; air ambulance (non-emergent); ABA; genetic testing (BRCA and LGR); specified surgical services (morbid obesity, breast reduction/augmentation not related to cancer, gender reassignment, oral/maxillofacial, orthognathic, orthopedic, reconstructive other than breast, rhinoplasty, septoplasty, varicose vein treatment); outpatient IMRT; hospice; cardiac and pulmonary rehabilitation; cochlear implants; outpatient residential treatment centers; specialty DME; radiology (MRI, CT, PET); transplants except cornea and kidney; blood or marrow stem cell transplants; transplant travel and related items.

ALL of the following

Members/providers should contact the Local Plan for precertification and prior-approval information; phone and fax contact numbers are provided in plan materials.
Prior approval requirements may differ when Medicare or another payer is primary; coordinate benefits per plan guidance.

Precertification, Prior Approval & Provider Contact Requirements

Prior Authorization

Precertification / Prior-approval contact requirements

Members must contact the Local Plan before being admitted to a hospital for inpatient care, or within two business days following the admission when the hospital admission is an emergency. Precertification is the contractual requirement; prior-approval is precertification for outpatient services. Precertification phone: 800-860-2156 (8AM - 7PM ET) Monday-Friday; FAX: 800-732-8318.

Precertification required before inpatient admission or within 2 business days after emergency admission
Prior-approval = precertification for outpatient services
Precertification phone: 800-860-2156; FAX: 800-732-8318

Prior Authorization

Services requiring prior approval

Prior approval is required for a range of inpatient and outpatient services as listed in the plan, including inpatient stays beyond the federal minimum LOS, emergency admissions (notification within 2 business days), all solid organ and bone marrow/stem cell transplants, applied behavior analysis (ABA), gene therapy/cellular immunotherapy, outpatient IMRT for specified cancers, outpatient surgery for morbid obesity, hospice care, and other procedures specified under Blue Focus.

Inpatient stays beyond federal minimum LOS and emergency admissions (notify Plan within 2 business days) [chunk 1]
Inpatient admits for all solid organ and bone marrow/stem cell transplants (transplant prior approval does not apply for kidney or cornea in some outpatient listings) [chunks 1,2,6]
Applied behavior analysis (ABA) prior approval required [chunks 2,6]
Gene therapy and cellular immunotherapy prior approval required [chunks 2,6]
Outpatient IMRT prior approval required for cancers other than head, neck, breast or prostate; brain cancer requires prior approval [chunk 2]
Blue Focus: additional specific surgical, radiology, transplant, and other services require prior approval; $100 penalty applies when prior approval not obtained for professional/outpatient facility claims [chunk 6]

Denial Risk

RTC precertification requirement and denial risk

Precertification must be obtained prior to Residential Treatment Center admission; if precertification is not obtained, the entire admission is 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 [chunk 10]
Facility must provide a preliminary treatment plan and a discharge plan prior to admission [chunk 10]

Documentation Required

MHSA contact and telehealth

For Mental Health/Substance Abuse services, contact MHSA at 800-424-4011 (8AM - 5PM ET) Monday-Friday or FAX 866-793-0469; telehealth services are available via www.fepblue.org/telehealth or by calling 855-636-1579 (TTY: 855-636-1578).

MHSA phone: 800-424-4011; FAX: 866-793-0469 [chunk 7]
Telehealth access: www.fepblue.org/telehealth or 855-636-1579 (TTY: 855-636-1578) for non-emergency medical issues and behavioral care [chunk 7]

OpenPayer

Precertification / Prior Approval Requirements (FEP)

Prior Approval and Coverage Rules

Codes and Coding Limitations

Precertification, Prior Approval & Provider Contact Requirements

Terminology and Member Requirements