2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 3. How You Get Care
Page 21
Section 3. How You Get Care
Page 21
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.
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, 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 22-26. Our FEP medical policies may be found by visiting www.fepblue.org/policies.
• Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility 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, inpatient residential treatment center, or skilled nursing facility whether or not they have contacted us and provided all necessary information. You may contact us at the phone 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 or a skilled nursing facility. For information about precertification of an emergency inpatient hospital admission, please see page 26.
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, or, when Medicare Part A is not the primary payor, at a skilled nursing facility. 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 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, 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 22-26. Our FEP medical policies may be found by visiting www.fepblue.org/policies.
• Inpatient hospital admission, inpatient residential treatment center admission, or skilled nursing facility 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, inpatient residential treatment center, or skilled nursing facility whether or not they have contacted us and provided all necessary information. You may contact us at the phone 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 or a skilled nursing facility. For information about precertification of an emergency inpatient hospital admission, please see page 26.
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, or, when Medicare Part A is not the primary payor, at a skilled nursing facility. 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 affirming surgery and admissions to residential treatment centers, and skilled nursing facilities.
- You have another group health insurance policy that is the primary payor for the hospital stay; with the exception of admissions for gender affirming surgery. (See page 76 for special instructions regarding admissions to Blue Distinction Centers for Transplants.)
- Medicare Part A is the primary payor for the hospital or skilled nursing facility stay; with the exception of admissions for gender affirming surgery. (See page 76 for special instructions regarding admissions to Blue Distinction Centers for Transplants.)
Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then you do need precertification.
Note: Morbid obesity surgery performed during an inpatient stay (even when Medicare Part A is your primary payor) must meet the surgical requirements described on pages 64-65 in order for benefits to be provided for the admission and surgical procedure.