Precertification Requirement Grids

Transcription

1 Precertification Requirement Grids BCBSAZ Precertification Requirements * Page 1 Banner Health HSA Page 2 City of Mesa Out of State Page 3 City of Phoenix Page 4 FEP Page 5 Fort Mojave Indian Tribe Page 6 Gila River Gaming Page 7 Snell & Wilmer Page 8 State of Arizona (ADOA) Page 9 *Refer also to the Alpha Prefix Grid for Large Group Alpha Prefixes. Please Note: Precertification is not a guarantee of coverage or payment, and is based on questions asked and information provided. Although precertification may not be required for a particular service, the claim for the service may still be subject to review for medical necessity, benefits, limitations, exclusions and waivers, if applicable. Providers have access to online eligibility and benefits verification, benefit plan summaries, medical coverage guidelines and the interactive voice response (IVR) system to assist in pre-service coverage determinations. You can check with the Utilization Management vendor for certain large groups if this information is not provided by BCBSAZ. This matrix is intended as a general summary only and is subject to change without notice. Precertification requirements are found in and governed by the member s benefit plan. Some large (100+) groups may customize certain benefits including adding or deleting precertification requirements. Refer to the large group custom precertification grids for these groups. Please note the revision date.

2 Precertification Requirements Out-of-State Provider Precertification Requests = Requires Precertification Alpha Prefix *Other group-specific alpha prefixes may be assigned to certain local groups. Click on the following link for the BCBSAZ Alpha Prefix Grid on azblue.com. Procedure/Service Briova Specialty Pharmacy Phone: (800) BCBSAZ Specialty Pharmacy (Click here)* Phone: (602) or (800) Option 4 BCBSAZ Retail & Mail Order R Meds (Click here)* Phone: (866) Pharmacy Benefits Manager Retail & Mail Order Rx Meds. Phone: (866) No precertification is required for outpatient services, unless otherwise specified. 1) For HMO product lines (BH, & BK), the behavioral services administrator (BSA) is the exclusive provider to precertify and manage behavioral and mental health care benefits. For outpatient behavioral health services, members must coordinate care through the BSA. Care coordination means that the member needs to contact the BSA prior to receipt of care to discuss the most appropriate provider and course of treatment. Call the BSA at (800) to precertify or coordinate services. 2) Some PPO plans provide behavioral health benefits through both the BSA and the BCBSAZ network. For benefits through BSA, call (800) ) Services are excluded from coverage for Blue Solutions. 4) Certain medications provided under the home health/home infusion benefit require precertification. A listing of the medications requiring precertification is available at azblue.com. Select Prescription Medications, and click on the link that says List of home health and specialty medications requiring precertification or call at the phone number listed above. 5) Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity and pre-term labor.) 6) PPO benefit plans have an out-of-network benefit, however, when there is not a PPO network specialist or facility available, BCBSAZ may, prior to delivery of services, precertify the member for the in-network coinsurance and deductible. Members remain responsible for any balance bill. The precertification request for this may be initiated by the referring or treating provider. 7) Please call for benefits/precertification requirements regarding autism services. 8) City of Glendale only. 1 HMO HMO PPO BH BK BB BP BR BN Product Type Suite E PPO BA BE BG BI BJ BF Custom 100+ Autism - Behavioral Therapy for Autism Spectrum Disorder (ASD) (7) (2:CGF) PD KTO MUM KGM BM CGF Indemnity (1,5) (2,3,5) (2,5) Behavioral & Mental Health services Scheduled IP admissions only Clinical Trials Cochlear Implants Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission BC Detoxification (non-emergency only) (3,5) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Home Infusion Care (for certain medications only) Home Health visits (Skilled nurse visits) (8) (1,5) (1,5) Major Organ & Bone Marrow Transplants & Stem Cell procedures MRI / MRA / CT / PET Scans (outpatient facility) (HMO) (6) (6) (6) Pharmacy Benefit & Precertification Requirements / Lists (Refer to the back of the Member s ID card for R information) *Click on the appropriate link below, or call the contact number listed to see the list of medications that require precertification.

3 Banner Health HSA Out-of-state Provider Precertification Requests = Requires Precertification Banner Health HSA Procedures/Services Alpha Prefix = PPO Group #: Behavioral & Mental Health services Clinical Trials Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) Inpatient Rehabilitation services Infertility Major Organ, Tissue or Bone Marrow Transplants & Stem Cell procedures (3) Covered when In-Network provider unavailable Pharmacy Benefit & Precertification Requirements / Lists Drugs that require precert are listed on this website. If precert required physician must fax request to (800) Express Scripts Phone: (800) ) Mental Health (substance abuse treatment, intensive outpatient program, mental health outpatient): CIGNA (800) ) Notification within 48 hours following admission is required for all medical emergent/urgent inpatient admissions. 3) Optum: (888) BNE 2

4 Customer Precertification Requirements for City of Mesa Out-of-State Members Out-of-State Provider Precertification Requests = Requires Precertification Alpha Prefix = PPO Group #: Procedure / Service Ambulance, excluding 911 initiated emergency transport Autism Applied Behavioral Analysis, Behavioral Therapy for Autism Spectrum Disorder (ASD) Bariatric Surgery (Weight Management) Behavioral & Mental Health services - Inpatient and intensive outpatient Cancer Clinical Trials Cardiac Rehabilitation Inpatient only Chiropractic Care (after 25 visits only) Cochlear Implants Cosmetic /Experimental/Investigative services Detoxification (Urgent and Scheduled Inpatient Admissions) DME/Prosthetics with a cost over $1000 Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Home Health Care & Home Infusion services Hospice Inpatient Admission ALL elective admissions, excluding maternity. Notification of emergency admission required within 48 hours. Major Organ & Bone Marrow Transplants & Stem Cell procedures Newborn stays beyond the mother Out-of-Network provider Outpatient Surgery in a free-standing or hospital-based surgery center/facility Outpatient Therapies Physical, Occupational, Speech & Music Pain Management treatments Sleep studies/testing Synagis injections for RSV Testosterone Treatments (pellets or shots) Prescription Drug Benefit and Specialty Pharmacy CVS/Caremark Phone: (855) Pharmacy Benefit & Precertification Requirements / Lists City of Mesa Out of State Members MDK 3

5 = Requires Precertification Procedures/Services Acupuncture Blue Cross Blue Shield of Arizona City of Phoenix Out-of-state Provider Precertification Requests Autism - Behavioral therapy for Autism Spectrum Disorder (ASD) Behavioral & Mental Health services Inpatient & intensive outpatient Cancer Clinical Trials Chiropractic services Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Home Health Care & Home Infusion services Inpatient Admissions Scheduled IP admissions only Intensive OP Programs Chemical Dependency or Behavioral Health Major Organ, Tissue or Bone Marrow Transplants & Stem Cell procedures MRA / MRI / PET Scans (outpatient facility) Alpha Prefix = PPO (Blue Preferred, Blue Preferred Saver) HMO (Blue Choice) Group # s: 40000, 40001, 40002, 40003, City of Phoenix Outpatient Behavioral Health services Outpatient Therapies Physical, Occupational & Speech (over 60 visits combined) PPO & HMO Pharmacy Benefit & Precertification Requirements / Lists Retail Pharmacy benefits administration - Contact Cigna for any precertification requirements. Cigna Member Services: (800) Cigna Home Delivery: (Mail Order) Quickswitch: (800) Cigna Specialty Pharmacy: (800) Cigna Home Delivery: (Mail Order) (800) SAVER Pharmacy Benefit & Precertification Requirements / Lists Pharmacy benefits administration through BCBSAZ. Precertification is required for certain injectables and medications. Click below links for specific medications. BCBSAZ Specialty Self- Injectable Benefit (Click here for list) of medications that require precertification. Phone: (602) , (800) Option 4 BCBSAZ Retail & Mail Order R Meds (Click here) for the list of medications that require precertification. Phone: (866) PO BO (HMO only) (1,2) (HMO only) (3) (HMO only) 1) For the HMO product line (BO), the behavioral services administrator (BSA) is the exclusive provider to precertify and manage behavioral health care benefits. Call the BSA at (800) to precertify and coordinate services. 2) Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.) 3) PPO benefit plan structures have an out-of-network benefit, however, when there is no PPO network specialist or facility available, BCBSAZ may, prior to the delivery of services, precertify the member for the in-network coinsurance and deductible. Members remain responsible for any balance bill. The precertification request for this may be initiated by the referring or treating provider. 4

6 Service Benefit Plan Precertification / Prior Approval Requirements Federal Employee Program (FEP) Phone: (602) or (800) Weekends and Holidays, call = Requires Precertification/Prior Approval Federal Employee Program Alpha Prefix R Procedures / Service Clinical Trials (for certain organ/tissue transplants) Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (Urgent & Scheduled IP admissions) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Emergency Admission notify within 2 business days following the day of ER admission (Notify BCBSAZ even if the patient has been discharged) Hospice Maternity admission stays > 48 hrs. post vaginal delivery and > 96 hrs. post C-section (3) Newborn Stays for additional days Major Organ & Blood or Marrow Transplants (BMT) & Stem Cell procedures Outpatient Surgery for the following procedures: Morbid obesity Surgical correction of congenital anomalies Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof & floor of mouth Outpatient Intensity - Modulated Radiation Therapy (IMRT) for certain diagnoses (6) Pharmacy Benefit & Supplies Precertification Requirements / Lists A listing of prescription drugs requiring prior approval are detailed online at fepblue.org under the Pharmacy tab. FEP Clinical Call Center Phone: (877) Hours: 7 a.m. and 9 p.m. Eastern Time, Monday - Friday 1) For clinical trials for certain organ/tissue transplants, contact the FEP organ transplant line at (602) Refer to the 2015 Service Benefit Plan brochure (RI ), online at fepblue.org. 2) For Mental Health and Substance Abuse inpatient admissions only, please call Biodyne at (888) For all other scheduled admissions, call (602) or (800) ) Precertification on maternity admissions for routine delivery is not required. However, if the member s medical condition requires the member to stay more than 48 hours after a vaginal delivery, or 96 hours after a cesarean section, then the physician or hospital must contact BCBSAZ for precertification of the additional days. Further, if the newborn stays after the discharge of the mother, then the physician or hospital must contact BCBSAZ for the precertification of the additional days for the newborn. 4) BMTs for certain diagnoses are required to be performed at a Cancer Research Facility, Blue Distinction Center for Transplants (BDCT), or a Foundation for the Accreditation of Cellular Therapy (FACT) and only when performed as part of a clinical trial. A list of these providers can be viewed on the Federal Employee Program website, fepblue.org. Contact the FEP transplant coordinator at (602) Refer to pages 67 through 74 in the 2015 Service Benefit Plan brochure (RI ) for details on the transplant benefits and that all the requirements are met. 5) Prior approval is not required for IMRT related to the treatment of head, neck, breast, or prostate cancer. 6) The Federal Employee Program does not have a SNF benefit, except as outlined in the Service Benefit Plan brochure (RI ) accessible online at fepblue.org; however a flexible benefits option may be available. 5

7 Fort Mojave Indian Tribe Out-of-State Provider Precertification Requests. Eff. 01/01/15 = Requires Precertification Ft. Mojave Procedure / Service Alpha Prefix = PPO Group #: Behavioral & Mental Health services Scheduled IP admissions only Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) Inpatient Rehabilitation services Home Infusion services (for certain medications only) Major Organ & Bone Marrow Transplants & Stem Cell procedures (3) Pharmacy Benefit and Precertification Requirements / Lists Call the contact numbers listed below to inquire about a list of the medications that require precertification. Briova Specialty Pharmacy Phone: (800) Pharmacy Benefits Manager - Retail & Mail Order Rx Meds Phone: (866) No precertification is required for outpatient services, unless otherwise specified. 1) Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.) 2) Certain medications provided under the home health/home infusion benefit require precertification. A listing of the medications requiring precertification is available at azblue.com. Select Prescription Medications, and click on the link that says List of home health and specialty medications requiring precertification or call Provider Assistance at the phone number listed above. 3) EPO benefit plans do not have an out-of-network benefit other than for emergency services. B 6

8 Gila River Gaming Eff. 01/01/15 = Requires Precertification Procedure / Service Out-of-State Provider Precertification Requests. Alpha Prefix = PPO Group #: Behavioral & Mental Health services & Substance Use disorders Scheduled IP admissions only Cancer Clinical Trials Extended Active Rehabilitation (EAR) Inpatient Rehabilitation services Home Infusion services (for certain medications only) Major Organ & Bone Marrow Transplants & Stem Cell procedures Gila River Gaming Pharmacy Benefit and Precertification Requirements / Lists Call the contact numbers listed below to inquire about a list of the medications that require precertification. Briova Specialty Pharmacy Phone: (800) BCBSAZ Retail & Mail Order R Meds (Click here) Phone: (866) No precertification is required for outpatient services, unless otherwise noted above. GLK 1) Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.) 2) Certain medications covered under home health benefit require precertification. A listing of the medications requiring precertification is available at azblue.com. Select Prescription Medications, and click on the link that says List of home health and specialty medications requiring precertification or call at the phone number listed above. 7

9 Snell & Wilmer = Requires Precertification Procedure / Service Out-of-State Provider Precertification Requests. Alpha Prefix = PPO & HSA Group #: Behavioral & Mental Health services & Substance Use disorders Scheduled IP admissions only Cancer Clinical Trials Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (non-emergency only) Durable Medical Equipment/Prosthetics (for rental/purchase price >$1500) Extended Active Rehabilitation (EAR) Inpatient Rehabilitation services Home Infusion services (for certain medications only) Home Health visits (Skilled Nurse visits, PT, OT, ST) Major Organ & Bone Marrow Transplants & Stem Cell procedures Snell & Wilmer Pharmacy Benefit and Precertification Requirements / Lists Call the contact numbers listed below to inquire about a list of the medications that require precertification. Briova Specialty Pharmacy Phone: (800) BCBSAZ Retail & Mail Order R Meds (Click here) Phone: (866) No precertification is required for outpatient services, unless otherwise specified. 1) Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.) 2) Certain medications provided under the home health/home infusion benefit require precertification. A listing of the medications requiring precertification is available at azblue.com. Select Prescription Medications, and click on the link that says List of home health and specialty medications requiring precertification or call at the phone number listed above. 3) PPO benefit plans have an out-of-network benefit, however, when there is not a PPO network specialist or facility available, BCBSAZ may, prior to delivery of services, precertify the member for the in-network coinsurance and deductible. Members remain responsible for any balance bill. The precertification request for this may be initiated by the referring or treating provider. SWB (3) 8

10 State of Arizona (ADOA) Large groups may customize certain benefits, including adding/ deleting benefits and precertification requirements. The group listed below has variations to standard BCBSAZ precertification requirements. Eligibility, benefit and precertification information can also be obtained online at azblue.com on the eligibility/benefit screen or by calling the Department at the number listed below. This matrix is intended as a general summary only and is subject to change without notice. Precertification requirements are found in and governed by the member s benefit plan. = Requires Precertification Procedure / Service Autism Spectrum Disorder Treatment :. Out-of-state Provider Precertification Requests: Ambulance (Non-emergency ambulance transportation) Alpha Prefix = PPO & EPO Group #: Behavioral/Mental Health Services- Including inpatient & Non-DRG inpatient behavioral health facilities (Emergency admits and detoxification) Biofeedback Cancer Clinical Trials Cochlear Implants (Hearing aids) Dental (Accidental dental services, dental confinement) Dialysis (End stage renal disease services) Durable Medical Equipment (Coverage for Purchase/Rental of DME and prosthetics > $ ; Repair or replacement of DME equipment & Prosthetics) Epidural and Facet injections Extended Active Rehabilitation Foot Orthotic Devices & Inserts Home Health/Home Infusion Care (Including parenteral) Injectable Medication in the Physician s office > $ Including but not limited to: Alefacept (Amevive); Etanercept (Enbrel); Sodium Hyaluronate (Hyalgan; Synvisc;, Infliximab (Remicade); Omaliizumab (olair); & Lupron Infusion/IV Therapy in an Outpatient Facility - Including but not limited to: Infliximab (Remicade); Alefacept (Amevive); and Etanercept (Enbrel) Inpatient Services (Includes elective & acute care emergency admits, Maternity services >48 hours for a normal delivery or 96 hours for a Cesarean delivery) Long Term Acute Care Medical Foods, Metabolic Supplements & Gastric Disorder Formula MRI / MRA / PET Scans / CAT / CT / ECT / BEAM (Brain Electrical Activity Mapping) outpatient and ambulatory NICU admission Organ transplant Services Orthognathic Treatment or Surgery Out-of-network Provider (Services not available through an in-network provider) Outpatient Ambulatory Cardiac Testing / Angiography / sleep testing-sleep studies and polysomnography / Video EEG Outpatient Surgery Radiofrequency Ablation MedImpact (800) Pharmacy Benefit and Precertification Requirements / Lists State of AZ SYD Services requiring precertification may vary upon group renewal date. Please verify by calling at the number listed above. 1) Notification and precertification is required within 48 hours following admission for all medical emergent/urgent inpatient admissions. 9