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Medical Pre-authorization

Federal Employee Program Medical Pre-authorization List
Effective July 1, 2013

Important pre-authorization reminders

  1. Failure to provide notification of inpatient admission or secure approval for services subject to pre-authorization will result in claim non-payment and provider liability. Asuris members may not be balance billed. View the notification regarding these requirements.
  2. Before requesting pre-authorization, please verify eligibility and benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. Contract exclusions will not be pre-authorized. Denials may be appealed through FEP Provider Customer Service.
  5. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
  6. Urgent/Emergent services do not require pre-authorization, but are subject to hospital admission notification requirements (see below).
  7. Pre-authorization decisions will be communicated.

Payment implications for failure to timely notify or pre-authorize services

Effective with admission dates of service on or after July 1, 2013, failure to provide notification of inpatient admission or secure approval for services subject to pre-authorization will result in claim non-payment and provider liability. Our members must be held harmless and cannot be balance billed.

Please note the following:

  • If the facility follows the inpatient admission and discharge notification requirement indicated above, they will not be subject to any pre-authorization penalties for failure by the physician or other health care professional to pre-authorize a service. We will review for medical necessity.
  • If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any penalties for failure of the facility to provide the required inpatient admission and discharge notification. We will review for medical necessity.
  • The following are facility pre-authorization requirements prior to patient admission:
    • Inpatient rehabilitation
    • Skilled nursing facility (SNF) care
    • Long term acute care facility (LTAC) care
    • Residential treatment for mental health and chemical dependency
  • An inpatient admission and discharge notification or pre-authorization do not guarantee payment for requested services. Regence reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be medically necessary.

Notification Timeframe Reimbursement
There will be four situations where exceptions to not obtaining a pre-authorization or failure to notify us of inpatient admissions may apply as part of our Administration Dispute Exception Criteria include:

  1. Member presented with an incorrect member card or member number.
  2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present are able to provide coverage information.
  4. Compelling evidence the provider or facility attempted to obtain pre-authorization or provide hospital admission notification. The evidence shall support the provider or facility followed our policy.

Note: A copy of the provider's or facility's fax cover sheet indicating the member health plan information and a fax confirmation from the fax machine showing the fax was successfully sent to the appropriate health plan fax number will be considered compelling evidence.

Learn how to appeal an administrative denial.

 

Chemical Dependency and Mental Health
Contact Blue Cross of Idaho Medical Management at 1 (877) 908-0972
Inpatient Admissions
Contact Blue Cross of Idaho Medical Management at 1 (866) 482-2250
Hospice Services - Inpatient

Contact Blue Cross of Idaho Medical Management at 1 (866) 482-2250

Hospice Services - Outpatient
Phone:  1 (800) 423-6884 or Fax: (800) 453-4341

Regence uses Milliman Care Guidelines - End of Life Care PO-006 (Home Care) or End of Life Care PO-006 (Inpatient) as the basis for determining medical necessity for Hospice services.

S9123, S9126, S9214, T2042, T2043, T2044, T2045

For listings of Preferred hospice providers, use the National Doctor & Hospital Finder on the FEP website.

Other Services
Phone: 1 (800) 423-6884 or Fax: 1 (855) 232-0088
Congenital abnormalities - Outpatient Surgical correction

33813, 33814, 40700, 40701, 40702, 40703, 40720, 40761, 42000,42205, 42210, 42215, 42220, 42225, 50070, 50135, 50405, 61680, 61682, 61684, 61686, 61690, 61692, 61710, 63250, 63251, 63252

C8921

Obesity surgery (bariatric)

43644, 43645, 43770, 43771, 43773, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43888
Oral/Maxillofacial surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth. 21010, 21026, 21030, 21031, 21032, 21034, 21040, 21044, 21045, 21046, 21047, 21048, 21049, 21050, 21060, 21070, 21073, 21116, 21240, 21242, 21243, 21480, 21485, 21490, 29800, 29804, 40490, 40500, 40510, 40520, 40525, 40527, 40530, 40650, 40800, 40801, 40804, 40805, 40808, 40810, 40812, 40814, 40816, 40819, 40820, 40830, 40831, 41000, 41005, 41006, 41007, 41008, 41009, 41010, 41015, 41016, 41017, 41018, 41100, 41105, 41108, 41110, 41112, 41113, 41114, 41115, 41116, 41120, 41130, 41150, 41250, 41251, 41252, 41520, 42100, 42104, 42106, 42107, 42120, 42140, 42145, 42160, 42200, 42300, 42305, 42310, 42320, 42330, 42335, 42340
Outpatient intensity-modulated radiation therapy (IMRT) - prior approval is required for all outpatient IMRT services EXCEPT those related to treatment of the head, neck, breast, or prostate cancer. Prior approval is required for IMRT treatment of brain cancer. 77301, 77418, 0073T
Organ/tissue transplants 32853, 32854, 33935, 33945, 38205, 38206, 38230, 38232, 38240, 38241, 38242, 38243, 44135, 44136, 47135, 47136, 48160, 48554, 32851, 32852, G0341, G0342, G0343, S2053, S2054, S2060, S2065, S2140, S2142, S2150, S2152
Clinical Trials for certain organ/tissue transplants – for blood or marrow stem cell transplants. S9988, S9990, S9991
Certain prescription drugs require Prior Authorization  Contact CVS Caremark at 1 (800) 624-5060 to request prior approval or to obtain a list of the drugs that require prior approval.