2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 19
 
You need prior Plan approval for certain services

The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for Other services (called prior approval) are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us before you receive medical care or services. In other words, a pre-service claim for benefits may require precertification and prior approval. If you do not obtain precertification or prior approval as required, there may be a reduction or denial of benefits. Be sure to read all of the precertification and prior approval information below and on pages 20-22.

 
  • Inpatient hospital admission, inpatient residential treatment center admission
Precertification is the process by which – prior to your inpatient admission – we evaluate the medical necessity of your proposed stay, the procedure(s)/service(s) to be performed, the number of days required to treat your condition, and any applicable benefit criteria. Unless we are misled by the information given to us, we will not change our decision on medical necessity.

In most cases, your physician or facility will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician, hospital or inpatient residential treatment center whether or not they have contacted us and provided all necessary information. You may also contact us at the telephone number on the back of your ID card to ask if we have received the request for precertification. You are also responsible for enrolling in case management and working with your case manager if your care involves residential treatment. For information about precertification of an emergency inpatient hospital admission, please see page 25.


Note: Special rules apply when Medicare or another payer is primary, see tables on pages 22-23.
 
Warning:

We will reduce our benefits for the inpatient hospital stay by $500, even if you have obtained prior approval for the service or procedure being performed during the stay, if no one contacts us for precertification. If the stay is not medically necessary, we will not provide benefits for inpatient hospital room and board or inpatient physician care; we will only pay for covered medical services and supplies that are otherwise payable on an outpatient basis.

Note: If precertification was not obtained prior to admission, inpatient benefits (such as room and board) are not available for inpatient care at a residential treatment center. We will pay only for covered medical services and supplies that are otherwise payable on an outpatient basis.

 
Exceptions:

You do not need precertification in these cases:

You are admitted to a hospital outside the United States; with the exception of admissions for gender reassignment surgery and admissions to residential treatment centers. 

Note: Special rules apply when Medicare or another payer is primary, see the tables on pages 22-23.

 
  • Other services
You must obtain prior approval for these services. Failure to obtain prior approval will result in a $100 penalty. Precertification is also required if the service or procedure requires an inpatient hospital admission. However, special rules apply when Medicare or another payer is primary, see tables on pages 22-23. If an inpatient admission is necessary, precertification is also required. Contact us using the customer service telephone number listed on the back of your ID card before receiving these types of services, and we will request the medical evidence needed to make a coverage determination:
 
  • Gene Therapy and Cellular Immunotherapy, including Car-T and T-cell receptor therapy
     
  • Air Ambulance Transport (non-emergent) – Air ambulance transport related to immediate care of a medical emergency or accidental injury does not require prior approval; see Section 5(c), page 82, for more information.
     
  • Applied behavior analysis (ABA) – Prior approval is required for ABA and all related services, including assessments, evaluations, and treatments.
     
  • Genetic testing including the following:
     
    • BRCA screening or diagnostic testing
       
    • Large genomic rearrangements of the BRCA1 and BRCA2 genes screening or diagnostic testing