Preauthorization Program Effective Date: 01/01/2015 PPO, COMP, POS
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1 SERVICES REQUIRING PREAUTHORIZATION Members should present their identification card to their health care provider when medical services or items are requested. When members use a participating provider (including a BlueCard facility participating provider providing inpatient services), the participating provider will be responsible for obtaining the If members use a non-participating provider or a BlueCard participating provider providing non-inpatient services, the non-participating provider or BlueCard participating provider may call for preauthorization on the member s behalf; however, it is ultimately the member s responsibility to obtain Providers and members should call Capital s Clinical Management Department toll-free at to obtain the necessary Providers/Members should request Preauthorization of non-urgent admissions and services well in advance of the scheduled date of service (15 days). Investigational or experimental procedures are not usually covered benefits. Members should consult their Certificate of Coverage, Capital BlueCross Medical Policies, or contact Customer Service at the number listed on the back of their health plan identification card to confirm coverage. Participating providers and Members have full access to Capital s medical policies and may request preauthorization for experimental or investigational services/items if there are unique member circumstances. Capital only pays for services and items that are considered medically necessary. Providers and members can reference Capital s medical policies for questions regarding medical necessity. PREAUTHORIZATION OF MEDICAL SERVICES INVOLVING URGENT CARE If the member s request for preauthorization involves urgent care, the member or the member s provider should advise Capital of the urgent medical circumstances when the member or the member s provider submits the request to Capital s Clinical Management Department. Capital will respond to the member and the member s provider no later than seventytwo (72) hours after Capital s Clinical Management Department receives the preauthorization request. PREAUTHORIZATION PENALTY APPLICABILITY Failure to obtain preauthorization for a service could result in a payment reduction or denial for the provider and benefit reduction or denial for the member, based on the provider s contract and the member s Certificate of Coverage. Services or items provided without preauthorization may also be subject to retrospective medical necessity review. If the member presents his/her ID card to a participating provider in the 21-county area and the participating provider fails to obtain or follow preauthorization requirements, payment for services will be denied and the provider may not bill the member. When members undergo a procedure requiring preauthorization and fail to obtain preauthorization (when responsible to do so), benefits will be provided for medically necessary covered services. However, in this instance, the allowable amount may be reduced by the dollar amount or the percentage established in the Certificate of Coverage. The table that follows is a partial listing of the preauthorization requirements for services and procedures.
2 Category Details Comments Inpatient Admissions Diagnostic Services Durable Medical Equipment (DME), Prosthetic Appliances& Orthotic Devices Observation care admissions Acute care Long-term acute care Non-routine maternity admissions Skilled nursing facilities Rehabilitation hospitals Behavioral Health (mental health care/ substance abuse) includes partial hospitalization & intensive outpatient programs Genetic disorder testing except: standard chromosomal tests, such as Down Syndrome, Trisomy, and Fragile X, and state mandated newborn genetic testing Cardiac nuclear medicine studies including nuclear cardiac stress tests CT (computerized tomography) scans MRA (magnetic resonance angiography) MRI (magnetic resonance imaging), PET (positron emission tomography) scans SPECT (single proton emission computerized tomography) scans Purchases and Repairs greater than or equal to $500 Rentals for DME regardless of price per unit Emergent/Urgent admissions to observation or inpatient status require notification within two (2) business days. All such services will be reviewed and must meet medical necessity criteria from the first hour of admission. Failure to notify Capital BlueCross of an admission may result in an administrative denial. Non-routine maternity admissions require notification within two (2) business days of the date of admission. Preauthorization requirements do not apply to services provided by a hospital emergency room provider. If an inpatient admission or observation admission results from an emergency room visit, notification must occur within two (2) business days of the admission. If the hospital is a participating provider, the hospital is responsible for performing the notification. If the hospital is a nonparticipating provider and is not BlueCard, the member or the member s responsible party acting on the member s behalf is responsible for the notification Diagnostic services do not require preauthorization when emergently performed during an emergency room visit, observation stay, or inpatient admission.
3 Office Surgical Procedures When Performed in a Facility* Outpatient Surgery for Select Procedures Therapy Services Aspiration and/or injection of a joint Colposcopy Treatment of warts Excision of a cyst of the eyelid (chalazion) Excision of a nail (partial or complete) Excision of external thrombosed hemorrhoids; Injection of a ligament or tendon; Eye injections (intraocular) Oral Surgery Pain management (including facet joint injections, trigger point injections, stellate ganglion blocks, peripheral nerve blocks, SI joint injections, and intercostals nerve blocks) Proctosigmoidoscopy/flexible Sigmoidoscopy; Removal of partial or complete bony impacted teeth (if a benefit); Repair of lacerations, including suturing (2.5 cm or less); Vasectomy Wound care and dressings (including outpatient burn care) Weight loss surgery (Bariatric) Implantation electrical nerve stimulator Meniscal transplants, allografts and collagen meniscus implants (knee) Ovarian and Iliac Vein Embolization Photodynamic therapy Radioembolization for primary and metastatic tumors of the liver Radiofrequency ablation of tumors Transcatheter aortic valve replacement Valvuloplasty Hyperbaric oxygen therapy (non-emergency) Manipulation therapy (chiropractic and osteopathic) Occupational therapy Physical therapy
4 Reconstructive or Cosmetic Services and Items Pulmonary rehabilitation programs Respiratory Therapy Radiation therapy and related treatment planning and procedures performed for planning (such as but not limited to IMRT, proton beam, neutron beam, brachytherapy, 3D conform, SRS, SBRT, Gamma knife, EBRT, IORT, IGRT) Removal of excess fat tissue (Abdominoplasty/Panniculectomy and other removal of fat tissue such as Suction Assisted Lipectomy) Breast Procedures Breast Enhancement (Augmentation) Breast Reduction Mastectomy (Breast removal or reduction) for Gynecomastia Breast Lift (Mastopexy) Removal of Breast implants Correction of protruding ears (Otoplasty) Repair of nasal/septal defects (Rhinoplasty/Septoplasty) Skin related procedures Acne surgery Dermabrasion Destruction of premalignant skin cells Hair removal (Electrolysis/Epilation) Face Lift (Rhytidectomy) Removal of excess tissue around the eyes (Blepharoplasty/Brow Ptosis Repair) Mohs Surgery Treatment of Varicose Veins and Venous Insufficiency Transplant Surgeries Other Services Evaluation and services related to transplants Bio-engineered skin or biological wound care products Category IDE trials (Investigational Device Exemption) Clinical trials (including cancer related trials) Enhanced external counterpulsation (EECP) Home health care Preauthorization will include referral assistance to the Blue Distinction Centers for Transplant network if appropriate.
5 Home infusion therapy Eye injections (Intravitreal angiogenesis inhibitors) Laser treatment of skin lesions Non-emergency air and ground ambulance transports Radiofrequency ablation for pain management Facility based sleep studies for diagnosis and medical Management of obstructive sleep apnea Specialty medical injectable medications Enteral feeding supplies and services. PLEASE NOTE: This listing identifies those services that require preauthorization only as of the date it was printed. This listing is subject to change. Members should call Capital at (TDD number at ) with questions regarding the preauthorization of a particular service. This information highlights the standard. Members should refer to their Certificate of Coverage for the specific terms, conditions, exclusions and limitations relating to their coverage.
Preauthorization Program Effective Date: 01/01/2017 PPO, COMP, POS
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Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Trio HMO 0/25 OffEx Group Plan HMO Benefit Plan This Summary of Benefits shows the amount
Your Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $0 single/ 3x family Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue toward the outof-pocket maximum. With respect to family plans, an individual
Aetna Health of California, Inc.
Easily locate PrimeCare participating providers at www.aetna.com/docfind/primecare PLAN FEATURES Deductible (per calendar year) Member Coinsurance Lifetime Maximum Primary Care Physician Selection Referral
This plan is pending regulatory approval.
Bronze Full PPO 3000 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective October 1, 2015 THIS MATRIX IS INTENDED TO BE USED
Quick Reference Card Precertification/notification requirements Important contact information
Quick Reference Card Precertification/notification requirements Important contact information https://mediproviders.anthem.com/ky AKYPEC-1483-17 Easy access to precertification/notification requirements
HOW TO GET SPECIALTY CARE AND REFERRALS
THE BELOW SECTIONS OF YOUR MEMBER HANDBOOK HAVE BEEN REVISED TO READ AS FOLLOWS HOW TO GET SPECIALTY CARE AND REFERRALS If you need care that your PCP cannot give, he or she will refer you to a specialist
NY EPO OA 1-09 v Page 1
PLAN FEATURES Deductible (per calendar year) Member Coinsurance (applies to all expenses unless otherwise stated) Maximum Out-of-Pocket Limit (per calendar year) Lifetime Maximum (per member lifetime)