CurrentHighmark DelawarePolicy N/A

Federal Employee Program (FEP) services requiring prior authorization or notification

Lists Federal Employee Program (FEP) services that require prior authorization or prior notification under different plan designs (Standard & Basic and FEP Blue Focus) and applies to Highmark Delaware's administration of FEP benefits.

Policy Summary

PayerHighmark Delaware

PolicyFEP services requiring prior authorization or notification

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed services (for example BRCA testing, specified surgeries, high-technology radiology where marked, gene therapy, transplants) according to the member's plan design.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleservice categories listed

plan-specificplan-specific flags

severalexamples provided

Services Requiring Prior Authorization or Notification

Authorization/Notification flags by service

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.

ALL of the following

Genetic testing
- BRCA screening or diagnostic testing — Standard & Basic = X; FEP Blue Focus = X
- Large genomic rearrangements of the BRCA1 and BRCA2 genes screening or diagnostic testing — Standard & Basic = X; FEP Blue Focus = X
- Genetic testing for the diagnosis and/or management of an existing medical condition — Standard & Basic = .; FEP Blue Focus = X
Surgical services
- Outpatient surgery for morbid obesity — Standard & Basic = X; FEP Blue Focus = X
- Outpatient surgical correction of congenital anomalies — Standard & Basic = X; FEP Blue Focus = X
- Outpatient surgery to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth — Standard & Basic = X; FEP Blue Focus = X
- Gender reassignment surgery — Standard & Basic = X; FEP Blue Focus = X
- Breast reduction or augmentation not related to treatment of cancer — Standard & Basic = .; FEP Blue Focus = X
- Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ) — Standard & Basic = .; FEP Blue Focus = X
- Orthopedic procedures: hip, knee, ankle, spine, shoulder and all orthopedic procedures using computer-assisted musculoskeletal surgical navigation — Standard & Basic = .; FEP Blue Focus = X
- Reconstructive surgery for conditions other than breast cancer — Standard & Basic = .; FEP Blue Focus = X
- Rhinoplasty — Standard & Basic = .; FEP Blue Focus = X
- Septoplasty — Standard & Basic = .; FEP Blue Focus = X
- Varicose vein treatment — Standard & Basic = .; FEP Blue Focus = X
Other outpatient and specialty services
- Outpatient intensity-modulated radiation therapy (IMRT) — Standard & Basic = X; FEP Blue Focus = X
- Cardiac rehabilitation — Standard & Basic = .; FEP Blue Focus = X
- Cochlear implants — Standard & Basic = .; FEP Blue Focus = X
- Prosthetic devices (external), including microprocessor controlled limb prosthesis; electronic and externally powered prosthesis — Standard & Basic = .; FEP Blue Focus = X
- Pulmonary rehabilitation — Standard & Basic = .; FEP Blue Focus = X
Radiology
- High-technology radiology (MRI, CT, PET) — Standard & Basic = .; FEP Blue Focus = [marked X where indicated]
  Note: High-technology radiology related to immediate care of a medical emergency or accidental injury does not require prior approval.
Durable medical equipment and specialized therapies
- Specialty durable medical equipment (DME), rental or purchase (including specialty hospital beds) — Standard & Basic = .; FEP Blue Focus = X
- Gene therapy and cellular immunotherapy (for example CAR-T and T-Cell receptor therapy) — Standard & Basic = X; FEP Blue Focus = X
- Air ambulance transport (non-emergent) — Standard & Basic = X; FEP Blue Focus = X
- Outpatient sleep studies performed outside the home — Standard & Basic = X; FEP Blue Focus = .
- Applied behavior analysis (ABA) — Standard & Basic = X; FEP Blue Focus = X
Transplants and transplant-related services
- All covered organ/tissue transplants, except kidney and cornea — Standard & Basic = X; FEP Blue Focus = X
- Blood or marrow stem cell transplants — Standard & Basic = X; FEP Blue Focus = X
- Clinical trials for certain blood or marrow stem cell transplants — Standard & Basic = X; FEP Blue Focus = X
- Transplant travel — Standard & Basic = X; FEP Blue Focus = X
ALL of the following
- Services requiring prior notification (plan-designated) — Standard & Basic = Standard & Basic; FEP Blue Focus = FEP Blue Focus
- Maternity care — Standard & Basic = .; FEP Blue Focus = X

ref

title

Provider Responsibilities and Authorization Requirements

Prior Authorization

Genetic testing prior authorization

BRCA screening or diagnostic testing and large genomic rearrangement testing of the BRCA1 and BRCA2 genes require prior authorization for both Standard & Basic and FEP Blue Focus plans.

Prior Authorization

Surgical services prior authorization

Outpatient surgical procedures listed (including outpatient surgery for morbid obesity, outpatient surgical correction of congenital anomalies, outpatient surgery to correct accidental facial injuries, gender reassignment surgery, certain breast procedures, orthognathic and specified orthopedic procedures) require prior authorization for the plans where indicated.

Outpatient surgery for morbid obesity — Standard & Basic = X; FEP Blue Focus = X.
Outpatient surgical correction of congenital anomalies — Standard & Basic = X; FEP Blue Focus = X.
Outpatient surgery to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth — Standard & Basic = X; FEP Blue Focus = X.
Gender reassignment surgery — Standard & Basic = X; FEP Blue Focus = X.
Select orthopedic and reconstructive procedures and others as marked for FEP Blue Focus.

Prior Authorization

Radiology prior authorization and emergency exception

High-technology radiology (MRI, CT, PET) requires prior authorization where marked for FEP Blue Focus; examinations related to immediate care of a medical emergency or accidental injury do not require prior approval.

High-technology radiology includes MRI, CT scan, and PET scan.
Emergency/accidental-injury imaging for immediate care is exempt from prior authorization.

Prior Authorization

Specialized services prior authorization

Gene therapy and cellular immunotherapy (for example CAR-T and T‑Cell receptor therapy), non-emergent air ambulance transport, outpatient sleep studies performed outside the home, and applied behavior analysis are listed with plan-specific prior authorization or notification requirements.

Gene therapy and cellular immunotherapy (e.g., CAR-T, T‑Cell receptor therapy) — Standard & Basic = X; FEP Blue Focus = X.
Air Ambulance Transport (non-emergent) — Standard & Basic = X; FEP Blue Focus = X.
Outpatient sleep studies performed outside the home — Standard & Basic = X (FEP Blue Focus differs as marked).
Applied behavior analysis (ABA) — Standard & Basic = X; FEP Blue Focus = X.

Prior Authorization

Transplant-related prior authorization

All covered organ or tissue transplants except kidney and cornea, and blood or marrow stem cell transplants (including certain related clinical trials and transplant travel) require prior authorization for both Standard & Basic and FEP Blue Focus.

All covered organ/tissue transplants, except kidney and cornea transplants — Standard & Basic = X; FEP Blue Focus = X.
Blood or marrow stem cell transplants — Standard & Basic = X; FEP Blue Focus = X.
Clinical trials for certain blood or marrow stem cell transplants — Standard & Basic = X; FEP Blue Focus = X.
Transplant travel requires prior authorization — Standard & Basic = X; FEP Blue Focus = X.

Note

Prior notification required for some services

Certain services are designated as requiring prior notification rather than prior authorization depending on plan design; maternity care is one example marked for FEP Blue Focus as requiring notification or authorization per the plan designation.

Services requiring prior notification are identified per plan (Standard & Basic vs FEP Blue Focus).
Maternity care is marked differently by plan (Standard & Basic = . ; FEP Blue Focus = X).

Definitions and Examples

High-technology radiology — inv-10

DefinitionHigh-technology radiology includes magnetic resonance imaging (MRI), computed tomography (CT) scan, and positron emission tomography (PET) scan.

Usual authorization statusMay require prior authorization depending on plan designations (Standard & Basic; FEP Blue Focus).

ExceptionWhen related to immediate care of a medical emergency or accidental injury, prior approval is not required.

ContextListed under Radiology, high technology in the FEP services requiring prior authorization or notification document.

Gene therapy and cellular immunotherapy — inv-11

ExamplesGene therapy and cellular immunotherapy examples include CAR-T and T-Cell receptor therapy.

Authorization requirementListed as services requiring prior authorization under both Standard & Basic and FEP Blue Focus plan designations.

PlacementIncluded within the 'OTHER SERVICES' section of the FEP services requiring prior authorization or notification list.

Related servicesGrouped with other specialized services such as air ambulance (non-emergent), outpatient sleep studies (outside the home), and applied behavior analysis.

OpenPayer

Federal Employee Program (FEP) services requiring prior authorization or notification

Services Requiring Prior Authorization or Notification

Coding Notes and Exceptions

Provider Responsibilities and Authorization Requirements

Definitions and Examples