2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 24
 
• Special prior authorization situations related to coordination of benefits (COB) (cont.)

The table below provides the special situations regarding prior approval and precertification when another healthcare insurance is the primary payor.

 
Service Type: Inpatient hospital admission
Primary Payor: Other healthcare insurance
Precertification: No
Prior Approval: Not applicable

Service Type: Gender reassignment surgery when performed during an inpatient admission
Primary Payor: Other healthcare insurance
Precertification: Yes
Prior Approval: Yes

Service Type: Gender reassignment surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Other healthcare insurance
Precertification: Not applicable
Prior Approval: Yes

Service Type: Morbid obesity surgery when performed during an inpatient admission
Primary Payor: Other healthcare insurance
Precertification: No
Prior Approval: Yes

Service Type: Morbid obesity surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Other healthcare insurance
Precertification: Not applicable
Prior Approval: Yes

Service Type: Residential treatment center admission – inpatient
Primary Payor: Other healthcare insurance
Precertification: Yes
Prior Approval: Not applicable

Service Type: Residential treatment center – outpatient care
Primary Payor: Other healthcare insurance
Precertification: Not applicable
Prior Approval: Yes
 
  • Prior notification – Maternity care
We encourage you to notify us of your pregnancy during the first trimester. Please contact us at the telephone number on the back of your ID card and provide the following information:
 
  • Enrollee’s name and Plan identification number
     
  • Expected delivery date
     
  • Date of your first prenatal appointment
     
  • Name and telephone number of the provider (i.e., physician, nurse practitioner, nurse midwife) providing your prenatal, delivery, and postnatal care
     
  • Name and location of the place you intend to deliver (i.e., hospital, birthing center, your home)
     
  • If you plan to deliver in a hospital, the type of delivery and the estimated number of days you will be in the hospital.
     
We will advise you if any additional information is needed.
 
  • How to request precertification for an admission or get prior approval for Other services
You, your representative, your physician, or your hospital, residential treatment center or other covered inpatient facility must call us at the telephone number listed on the back of your ID card any time prior to admission or before receiving services that require prior approval with the following information:
 
  • Enrollee’s name and Plan identification number;
     
  • Patient’s name, birth date, and telephone number;
     
  • Reason for inpatient admission, proposed treatment, or surgery;
     
  • Name and telephone number of admitting physician;
     
  • Name of hospital or facility;
     
  • Number of days requested for hospital stay;