2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 23
Section 3. How You Get Care
Page 23
• Warning:
We will reduce our benefits by $100 for medically necessary services that require prior approval, if no one contacts us for prior approval. If the service is not medically necessary, we will not provide benefits. This benefit reduction does not apply to prescription drugs that require prior approval, see page 22.
We will reduce our benefits by $100 for medically necessary services that require prior approval, if no one contacts us for prior approval. If the service is not medically necessary, we will not provide benefits. This benefit reduction does not apply to prescription drugs that require prior approval, see page 22.
• Special prior authorization situations related to coordination of benefits (COB)
The examples below provides the special situations regarding prior approval and precertification when Medicare is the primary payor.
Service Type: Inpatient hospital admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Not applicable
Service Type: Medicare hospital benefits exhausted and you do not want to use your Medicare lifetime reserve days
Primary Payor: Medicare Part A benefits not provided
Precertification: Yes
Prior Approval: Not applicable
Service Type: Gender affirming surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Yes
Service Type: Gender affirming surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Morbid obesity surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Yes
Service Type: Morbid obesity surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Residential treatment center admission – inpatient
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Not applicable
Service Type: Residential treatment center – outpatient care
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
The examples below provides the special situations regarding prior approval and precertification when Medicare is the primary payor.
Service Type: Inpatient hospital admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Not applicable
Service Type: Medicare hospital benefits exhausted and you do not want to use your Medicare lifetime reserve days
Primary Payor: Medicare Part A benefits not provided
Precertification: Yes
Prior Approval: Not applicable
Service Type: Gender affirming surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Yes
Service Type: Gender affirming surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Morbid obesity surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Yes
Service Type: Morbid obesity surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Residential treatment center admission – inpatient
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Not applicable
Service Type: Residential treatment center – outpatient care
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
The examples 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