Precertification Requirement Grids

(1)

Rev. 01/01/15

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)

Provider Assistance

(602) 864-4320 or (800) 232-2345, option 4 Out-of-State Provider Precertification Requests

(800) 676-2583

Rev. 01/01/15

No precertification is required for outpatient services, unless otherwise specified.

1) For HMO product lines (XBH, & XBK), 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) 224-2125 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) 224-2125. 3) 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 Provider Assistance 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

X = Requires Precertification

Product Type

HMO HMO PPO

Suite E PPO Custom 100+ Indemnity Alpha Prefix

*Other group-specific alpha prefixes may be assigned to certain local 1000+ groups. Click on the following link for the BCBSAZ Alpha Prefix Grid on azblue.com. XBH XBK XBB XBP XBR XBN XBA XBE XBG XBI XBJ XBF PXD KTO MUM KGM XBM CGF XBC Procedure/Service

Autism - Behavioral Therapy for Autism Spectrum Disorder (ASD) X (7) X X

Behavioral & Mental Health services – Scheduled IP admissions only

X (1,5) (5) X (2,3,5) (5) X (2:CGF) (5) X (2,5) Clinical Trials X X X X X X Cochlear Implants X

Dental related facility services or Dental related services integral to medical

services when scheduled as an inpatient admission X X X X X

Detoxification (non-emergency only)

X (5) X (5) X (3,5) X (5) X (5) X (5) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services X X X X X X Home Infusion Care (for certain medications only)

X (4) X (4) X (4) X (4) X (4) X (4)

Home Health visits (Skilled nurse visits) X (8)

Inpatient Admission – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions.

X (1,5) X (1,5) X (5) X (5) X (5) X (5)

Long Term Acute Care (LTAC) X X X X X X

Major Organ & Bone Marrow Transplants & Stem Cell procedures X X X X X X

MRI / MRA / CT / PET Scans (outpatient facility) X X

X (HMO) Out-of-Network Provider X X X (6) X (6) X (6)

Skilled Nursing Facility (SNF) X X X X X X

Pharmacy Benefit & Precertification Requirements / Lists (Refer to the back of the Member’s ID card for RX information)

*Click on the appropriate link below, or call the contact number listed to see the list of medications that require precertification. Briova Specialty Pharmacy

Phone: (800) 850-9122 X

BCBSAZ Specialty Pharmacy (Click here)*

Phone: (602) 864-4320 or (800) 232-2345 Option 4 X X X X X

BCBSAZ Retail & Mail Order RX Meds (Click here)*

Phone: (866) 325-1794 X X X X X

Pharmacy Benefits Manager Retail & Mail Order Rx Meds.

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Blue Cross Blue Shield of Arizona

Custom Precertification Requirements for

Banner Health HSA

2

(602) 864-4320 or (800) 232-2345, option 4 Out-of-state Provider Precertification Requests

(800) 676-2583 Rev. 01/01/15

X= Requires Precertification Banner Health HSA

Alpha Prefix = PPO

Group #: 50000 BNE Procedures/Services

Behavioral & Mental Health services (1)

Clinical Trials X

Detoxification (non-emergency only) X

Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services X

Infertility X

Inpatient Admission – Scheduled IP admissions only

X (2)

Long Term Acute Care (LTAC) X

Major Organ, Tissue or Bone Marrow Transplants & Stem Cell procedures (3) Out-of-Network Provider

Covered when In-Network provider unavailable X

Skilled Nursing Facility (SNF) X

Pharmacy Benefit & Precertification Requirements / Lists – www.bannerbenefits.com www.express-scripts.com - Drugs that require precert are listed on this website.

If precert required – physician must fax request to (800) 396-2971. Express Scripts

Phone: (800) 900-6337 X

1) Mental Health (substance abuse treatment, intensive outpatient program, mental health outpatient): CIGNA (800) 633-5954.

2) Notification within 48 hours following admission is required for all medical emergent/urgent inpatient admissions.

(4)

Customer Precertification Requirements for

City of Mesa Out-of-State Members

(800) 676-2583 Rev. 01/01/15 X = Requires Precertification City of Mesa Out of State Members Alpha Prefix = PPO

Group #: 29231 MDK

Procedure / Service

Ambulance, excluding 911 initiated emergency transport X Autism – Applied Behavioral Analysis, Behavioral Therapy for Autism Spectrum Disorder (ASD) X

Bariatric Surgery (Weight Management) X

Behavioral & Mental Health services - Inpatient and intensive outpatient X

Cancer Clinical Trials X

Cardiac Rehabilitation – Inpatient only X

Chiropractic Care (after 25 visits only) X

Cochlear Implants X

Cosmetic /Experimental/Investigative services X

Detoxification (Urgent and Scheduled Inpatient Admissions) X

DME/Prosthetics with a cost over $1000 X

Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services X

Home Health Care & Home Infusion services X

Hospice X

Inpatient Admission – ALL elective admissions, excluding maternity. Notification of

emergency admission required within 48 hours. X

Major Organ & Bone Marrow Transplants & Stem Cell procedures X

Newborn stays beyond the mother X

Out-of-Network provider X

Outpatient Surgery in a free-standing or hospital-based surgery center/facility X Outpatient Therapies – Physical, Occupational, Speech & Music X

Pain Management treatments X

Sleep studies/testing X

Synagis – injections for RSV X

Testosterone Treatments (pellets or shots) X

Pharmacy Benefit & Precertification Requirements / Lists Prescription Drug Benefit and Specialty Pharmacy

CVS/Caremark Phone: (855) 264-5048

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Blue Cross Blue Shield of Arizona

Custom Precertification Requirements for

City of Phoenix

4

(602) 864-4320 or (800) 232-2345, option 4 Out-of-state Provider Precertification Requests

(800) 676-2583

Rev. 01/01/15

X= Requires Precertification City of Phoenix

Alpha Prefix = PPO (Blue Preferred, Blue Preferred Saver) HMO (Blue Choice)

Group #’s: 40000, 40001, 40002, 40003, 40004

PXO XBO Procedures/Services

Acupuncture X

Autism - Behavioral therapy for Autism Spectrum Disorder (ASD)

X (1) Behavioral & Mental Health services – Inpatient & intensive outpatient

X (1)

Chiropractic services (HMO only) X

X (2) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services X

Home Health Care & Home Infusion services X

Inpatient Admissions – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions.

X (1,2) Intensive OP Programs – Chemical Dependency or Behavioral Health

X (1)

Major Organ, Tissue or Bone Marrow Transplants & Stem Cell procedures X MRA / MRI / PET Scans (outpatient facility)

X (HMO only) Out-of-Network Provider

X (3) Outpatient Behavioral Health services

X (HMO only) Outpatient Therapies – Physical, Occupational & Speech (over 60 visits combined) X

PPO & HMO Pharmacy Benefit & Precertification Requirements / Lists

Retail Pharmacy benefits administration - Contact Cigna for any precertification requirements.

Cigna Member Services: (800) 244-6224

Cigna Home Delivery: (Mail Order) Quickswitch: (800) 285-4812 Cigna Specialty Pharmacy: (800) 351-3606

Cigna Home Delivery: (Mail Order) (800) 835-3784

X 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) 864-4320, (800) 232-2345 Option 4 X

BCBSAZ Retail & Mail Order RX Meds (Click here) for the list of medications that require precertification.

Phone: (866) 325-1794 X

1) For the HMO product line (XBO), the behavioral services administrator (BSA) is the exclusive provider to precertify and manage behavioral health care benefits. Call the BSA at (800) 224-2125 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.

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Service Benefit Plan

Precertification / Prior Approval Requirements

Federal Employee Program (FEP)

Phone: (602) 864-4102 or (800) 345-7562

Weekends and Holidays, call (602) 864-4320 or (800) 232-2345, option 4

Rev. 01/01/15

X= Requires Precertification/Prior Approval Federal Employee

Program

Alpha Prefix R

Procedures / Service

Clinical Trials (for certain organ/tissue transplants) (1) Dental related facility services or Dental related services integral to medical services when

scheduled as an inpatient admission X

Detoxification (Urgent & Scheduled IP admissions) X

Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services X Emergency Admission – notify within 2 business days following the day of ER admission

(Notify BCBSAZ even if the patient has been discharged) X

Hospice X

 Maternity admission stays > 48 hrs. post vaginal delivery and > 96 hrs. post C-section

 Newborn Stays for additional days

X (2) (3)

Major Organ & Blood or Marrow Transplants (BMT) & Stem Cell procedures

X (4) 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

X

Outpatient Intensity - Modulated Radiation Therapy (IMRT) for certain diagnoses

X (5)

Skilled Nursing Facility (SNF) (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) 727-3784

Hours: 7 a.m. and 9 p.m. Eastern Time, Monday - Friday

X

1) For clinical trials for certain organ/tissue transplants, contact the FEP organ transplant line at (602) 864-4051. Refer to the 2015

Service Benefit Plan brochure (RI 71-005), online at fepblue.org.

2) For Mental Health and Substance Abuse inpatient admissions only, please call Biodyne at (888) 883-4451. For all other scheduled admissions, call (602) 864-4102 or (800) 345-7562.

3) 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) 864-4051. Refer to pages 67 through 74 in the 2015 Service Benefit Plan brochure (RI 71-005) for details on the transplant benefits and that all the requirements are met.

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Blue Cross Blue Shield of Arizona

Custom Precertification Requirements for

Fort Mojave Indian Tribe

6

(800) 676-2583

.

Eff. 01/01/15

X = Requires Precertification Ft. Mojave

Alpha Prefix = PPO

Group #: 29737 XBX Procedure / Service

Behavioral & Mental Health services – Scheduled IP admissions only

X (1) Dental related facility services or Dental related services integral to medical services when

X (1) Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services X Home Infusion services (for certain medications only)

X (2) Inpatient Admission – Scheduled IP admissions only

Includes medical, surgical & psychiatric admissions.

X (1)

Major Organ & Bone Marrow Transplants & Stem Cell procedures X Out-of-Network Provider

X (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) 850-9122 X

Pharmacy Benefits Manager - Retail & Mail Order Rx Meds

Phone: (866) 391-2370 X

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.

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Custom Precertification Requirements for

Gila River Gaming

(800) 676-2583

.

Eff. 01/01/15

X = Requires Precertification Gila River

Gaming Alpha Prefix = PPO

Group #: 30324 GLK Procedure / Service

Behavioral & Mental Health services & Substance Use disorders – Scheduled IP admissions only

X (1)

Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services X Home Infusion services (for certain medications only)

X (2) Inpatient Admission – Scheduled IP admissions only

Includes medical, surgical & psychiatric admissions.

X (1)

Major Organ & Bone Marrow Transplants & Stem Cell procedures X

Out-of-Network Provider X

Phone: (800) 850-9122

X (2) BCBSAZ Retail & Mail Order RX Meds (Click here)

Phone: (866) 325-1794

X (2) No precertification is required for outpatient services, unless otherwise noted above.

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 Provider Assistance at the phone number listed above.

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Blue Cross Blue Shield of Arizona

Custom Precertification Requirements for

Snell & Wilmer

8

(800) 676-2583

.

Rev. 01/01/15 X = Requires Precertification Snell & Wilmer Alpha Prefix = PPO & HSA

Group #: 30313 SWB Procedure / Service

Behavioral & Mental Health services & Substance Use disorders – Scheduled IP admissions only (1) X

Dental related facility services or Dental related services integral to medical services when

X (1) Durable Medical Equipment/Prosthetics (for rental/purchase price >$1500) X Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services X Home Infusion services (for certain medications only)

X (2)

Home Health visits (Skilled Nurse visits, PT, OT, ST) X

X (1)

Major Organ & Bone Marrow Transplants & Stem Cell procedures X Out-of-Network Provider

X (3)

Phone: (800) 850-9122 X

BCBSAZ Retail & Mail Order RX Meds (Click here)

Phone: (866) 325-1794 X

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) 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.

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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 Provider Assistance 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.

Provider Assistance: (602) 864-4320 or (800) 232-2345, option 4. Out-of-state Provider Precertification Requests: (800) 676-2583

Rev. 01/01/15

X = Requires Precertification State of AZ

Alpha Prefix = PPO & EPO

Group #: 030855 SYD Procedure / Service

Autism Spectrum Disorder Treatment X

Ambulance (Non-emergency ambulance transportation) X

Behavioral/Mental Health Services- Including inpatient & Non-DRG inpatient behavioral health facilities (Emergency admits and detoxification)

X (1)

Biofeedback X

Cochlear Implants (Hearing aids) X

Dental (Accidental dental services, dental confinement) X

Dialysis (End stage renal disease services) X

Durable Medical Equipment (Coverage for Purchase/Rental of DME and prosthetics > $1000.00; Repair or replacement of DME equipment & Prosthetics)

X

Epidural and Facet injections X

Extended Active Rehabilitation X

Foot Orthotic Devices & Inserts X

Home Health/Home Infusion Care (Including parenteral) X

Injectable Medication in the Physician’s office > $350.00 - Including but not limited to: Alefacept (Amevive); Etanercept (Enbrel); Sodium Hyaluronate (Hyalgan; Synvisc;, Infliximab (Remicade); Omaliizumab (Xolair); & Lupron

X

Infusion/IV Therapy in an Outpatient Facility - Including but not limited to: Infliximab (Remicade); Alefacept (Amevive); and Etanercept (Enbrel)

X Inpatient Services (Includes elective & acute care emergency admits, Maternity services >48 hours

for a normal delivery or 96 hours for a Cesarean delivery)

X (1)

Long Term Acute Care X

Medical Foods, Metabolic Supplements & Gastric Disorder Formula X MRI / MRA / PET Scans / CAT / CT / ECT / BEAM (Brain Electrical Activity Mapping) – outpatient

and ambulatory

X

NICU admission X

Organ transplant Services X

Orthognathic Treatment or Surgery X

Out-of-network Provider (Services not available through an in-network provider) X Outpatient Ambulatory Cardiac Testing / Angiography / sleep testing-sleep studies and

polysomnography / Video EEG

X

Outpatient Surgery X

Radiofrequency Ablation X

Pharmacy Benefit and Precertification Requirements / Lists MedImpact

(800) 648-6769

X