Precertification Requirements for Medical Services

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INTRODUCTION TO PRECERTIFICATION REQUIREMENTS FOR MEDICAL SERVICES Precertification Precertification is the process Blue Cross Blue Shield of Arizona (BCBSAZ) uses to determine eligibility for benefits. This document provides a list of types of healthcare services and whether or not they require precertification before you obtain services. When Is Precertification Required and What Happens If You Don t Obtain It Not all services require Precertification is not required for emergency services. If it is required, your provider must obtain it on your behalf before rendering services. Notwithstanding any other language in this precertification requirements document or in the benefit book, BCBSAZ may change the list of services and medications that require precertification at any time without notice. Check this list on www.azblue.com for updates each time you have a question about whether a service or medication requires You can also call the Customer Service number listed in the front of the benefit book. [Except for medications that require precertification, if required precertification is not obtained, your network provider will be penalized. If precertification is not obtained for medications that require precertification, your benefits will be denied.] How to Obtain Precertification Ask your provider to contact BCBSAZ for precertification before you receive services and medications that require Your provider must contact BCBSAZ because he or she has the information and medical records we need to make a benefit determination. BCBSAZ will rely on information supplied by your provider. If that information is inaccurate or incomplete it may affect the decision on your claim. You are responsible for checking with your provider to make sure the provider has obtained any required Factors BCBSAZ Considers in Evaluating a Precertification Request for Services or Medications 1. Applicability of other benefit plan provisions (limitations, exclusions and benefit maximums); 2. If the treating provider or location of service is a network provider; 3. Whether the service is medically necessary or investigational; and 4. Whether your coverage is active Some of these factors may not be readily identifiable at the time of precertification, but will still apply if discovered later in the claim process and could result in denial of your claim. Prescription Medication Exception If a covered medication requires precertification, but you must obtain the medication outside of BCBSAZ's precertification hours, you may have to pay the entire cost of the medication when it is dispensed. In such cases, you can file a reimbursement claim with BCBSAZ and have your provider request precertification on the next business day. Your claim for the medication will not be denied for lack of precertification, but all other exclusions and limitations of your plan will apply. Precertification of Network Cost-Share for Services from an Out-of-Network Provider If there is no network provider available to deliver covered services, your treating provider may contact BCBSAZ and ask BCBSAZ to precertify the network cost-share for services from an out-of-network provider. BCBSAZ will evaluate whether there is a network alternative. If BCBSAZ determines that a network provider is available to treat you, BCBSAZ will not precertify the services from your out-of-network provider of choice. 2

Precertification for use of an out-of-network provider is separate from, and required in addition to, any required precertification for the service. If BCBSAZ Precertifies Your Service 1. Precertification is not a pre-approval or a guarantee of payment. Any pre-certified service is subject to all other terms and conditions of your benefit plan. Precertification made in error by BCBSAZ is not a waiver of BCBSAZ s right to deny payment for noncovered services. 2. You and your provider will receive a letter explaining the scope of the If BCBSAZ Denies Your Precertification Request Denial of precertification is an adverse benefit determination. BCBSAZ will send you a notice explaining the reason for the denial, and your right to appeal the BCBSAZ decision. Information on where to file an appeal is in the BCBSAZ Customer Service section at the front of the benefit book. If your request for precertification of a service is denied because BCBSAZ decides that the service is not medically necessary, remember that BCBSAZ s interpretation of medical necessity is a benefits determination made in accordance with the provisions of this plan. Your provider may recommend services or treatment not covered under this plan. You and your provider should decide whether to proceed with the service or procedure if BCBSAZ denies REFERRAL REQUIREMENTS What is a Primary Care Provider (PCP) Primary Care Provider (PCP) means a health care professional who is contracted with BCBSAZ as a PCP and generally specializes in or focuses on the following practice areas: internal medicine, family practice, general practice, pediatrics or any other classification of provider approved as a PCP by BCBSAZ. What is PCP Referral PCP Referral is different than, and independent of, Precertification Requirements. Except as stated in the benefit book, you must obtain a referral from your designated PCP for all non-emergent and non-urgent professional Specialist services and other services as noted in the benefit book. The requirement to obtain a referral from your designated PCP does not apply to services from providers who specialize in obstetrics or gynecology, chiropractic services, outpatient mental health services, pediatric dental and vision services, urgent care, or services provided by walk-in clinics. If you do not obtain a referral from your designated PCP for services that require a referral, the services will not be covered under the benefit plan and you will be responsible for paying the provider s billed charges for those services. LIST OF PRECERTIFICATION REQUIREMENTS FOR MEDICAL SERVICES A. AMBULANCE SERVICES Precertification: Required for non-emergent air ambulance transportation. You will not be penalized if your B. BEHAVIORAL AND MENTAL HEALTH SERVICES (including chemical dependency or substance abuse treatment) B.1 Inpatient Hospital: 3

B.2 Inpatient Rehabilitation - Behavioral Health Facility Services B.3 Outpatient Facility and Professional Services: Precertification: Not Required. B.4 Behavioral Therapy Services For The Treatment Of Autism Spectrum Disorder Precertification: Not Required. C. CLINICAL TRIALS Precertification: Not Required. Please notify BCBSAZ if you are enrolled in a clinical trial to help us correctly process your claims for covered services associated with clinical trials. D. CATARACT SURGERY AND KERATOCONUS Precertification: Not required for outpatient surgery. Required for non-emergency inpatient admissions. You will not be penalized if your E. CHIROPRACTIC SERVICES Precertification: Not Required. F. DENTAL SERVICES BENEFIT - MEDICAL F.1 Dental Accident Services Precertification: Not Required. F.2 Dental Services Required for Medical Procedures F.3 Medical Services Required for Dental Procedures (Facility and Professional Anesthesia Charges) G. DURABLE MEDICAL EQUIPMENT (DME), MEDICAL SUPPLIES AND PROSTHETIC APPLIANCES AND ORTHOTICS Precertification: Required for certain services. You will not be penalized if your network provider fails to obtain Precertification required for certain services, including but not limited to: 1) Airway clearance devices (chest percussors, vests, etc.) 2) Muscle stimulator 3) Bone growth stimulator 4) Continuous glucose monitor 5) Custom/special seating system 6) Power wheelchair/scooter 7) Custom wheelchair 8) Prosthetics (except breast prosthetics) 9) Dynasplint/JAS (or other mechanical stretching device) 10) Sonic Accelerated Fracture Healing System 11) Enteral feedings/nutritional formulas 12) Spinal cord stimulator 4

13) External wearable cardiac defibrillator 14) Intrapulmonary percussive ventilation 15) INR Monitor, for home. H. CHRONIC DISEASE EDUCATION AND TRAINING (INCLUDING NUTRITIONAL COUNSELING AND TRAINING) I. EMERGENCY (PROFESSIONAL AND FACILITY CHARGES) J. EOSINOPHILIC GASTROINTESTINAL DISORDER K. FAMILY PLANNING (CONTRACEPTIVES AND STERILIZATION) L. HEARING AIDS AND SERVICES M. HOME HEALTH SERVICES N. HOSPICE SERVICES Precertification: Not required for inpatient hospice admissions. Required for non-emergency inpatient admissions not related to hospice services. You will not be penalized if your network provider fails to obtain O. INPATIENT AND OUTPATIENT DETOXIFICATION SERVICES P. INPATIENT HOSPITAL Q. INPATIENT REHABILITATION EXTENDED ACTIVE REHABILITATION (EAR) AND SKILLED NURSING FACILITY (SNF) SERVICES R. LONG-TERM ACUTE CARE (INPATIENT) S. MATERNITY Notify BCBSAZ customer service during your first trimester to facilitate maternity care coordination. 5

T. MEDICAL FOODS FOR INHERITED METABOLIC DISORDERS U. NEUROPSYCHOLOGICAL AND COGNITIVE TESTING V. OUTPATIENT SERVICES Precertification: Required as indicated in the Benefit Description listing below. You will not be penalized if your Benefit Description: Benefits are available for the following outpatient services, including but not limited to the following: 1) Allergy testing, antigen administration and desensitization treatment 2) Blood transfusions, whole blood, blood components and blood derivatives 3) Diagnostic testing, including but not limited to, laboratory and radiology services 4) Outpatient and ambulatory magnetic resonance imaging (MRI/MRA), PET Scans, ECT, BEAM (Brain Electrical Activity Mapping) Precertification Required 5) Epidural and facet injections, radio frequency ablation and biofeedback for pain management Precertification Required 6) Infusion/IV therapy in an outpatient setting Precertification Required 7) End-stage renal disease services (including dialysis) 8) CAT/CT imagery Precertification Required 9) Outpatient and ambulatory sleep testing (including sleep studies and polysomnography), video EEG Precertification Required 10) Dialysis 11) **Orthognathic treatment and surgery, including but not limited to dental and orthodontic services and/or appliances that are orthodontic in nature or change the occlusion of the teeth (external or intra-oral) Precertification Required 12) Outpatient surgery (which is defined as operative procedures and other invasive procedures) performed in a freestanding or hospital based surgery center that requires Precertification: a. Abdominoplasty b. Bariatric Surgery (See #16 below*) c. Blepharoplasty d. Cochlear Implant e. Hysterectomy f. Implantable devices including Cochlear Implant g. Laser Treatment (except for Retinopathy) h. Mammoplasty i. Orthognathic Services (See #11 above**) j. Otoplasty k. Rhinoplasty/Septoplasty l. Scar Revision m. Spinal Surgery n. Excision/Scraping/Shaving of Lesions o. Treatment of Varicose Veins p. Uvulopalatopharyngoplasty (UPP) q. Vagus Nerve Stimulation 13) Pre-operative testing 14) Radiation therapy or chemotherapy, unless performed in conjunction with a noncovered transplant 15) Treatment of TMJ 16) The following *Bariatric Surgery procedures: open roux-en-y gastric bypass (RYGBP), laparoscopic roux-en-y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), open biliopancreatic diversion with duodenal switch (BPD/DS), laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), and laparoscopic sleeve gastrectomy (LSG) Precertification Required 17) Other outpatient services required by state or federal law to be covered Precertification Requirement dependent on type of outpatient service. 6

W. PHARMACY BENEFIT Precertification (Prior Authorization): Required for certain medications. Contact the Pharmacy Benefit Customer Service number listed in the front of the benefit book for a list of medications that require If you do not obtain precertification for medications that require precertification, the medications will not be covered. X. PHYSICAL THERAPY (PT), OCCUPATIONAL THERAPY (OT), SPEECH THERAPY (ST), COGNITIVE THERAPY (CT) AND CARDIAC AND PULMONARY REHABILITATION SERVICES Precertification: Required after 60 therapy visits combined for all therapy types including both habilitation and rehabilitation services. You will not be penalized if your network provider fails to obtain Y. PHYSICAL THERAPY (PT), OCCUPATIONAL THERAPY (OT), SPEECH THERAPY (ST), COGNITIVE THERAPY (CT) AND CARDIAC AND PULMONARY HABILITATION SERVICES Precertification: Required after 60 therapy visits combined for all therapy types including both habilitation and rehabilitation services. You will not be penalized if your network provider fails to obtain Z. PHYSICIAN SERVICES AA. POST-MASTECTOMY SERVICES BB. PRESCRIPTION MEDICATIONS FOR THE TREATMENT OF CANCER Precertification: May be required depending on the medication received. Contact the Pharmacy Benefit Customer Service number listed in the front of the benefit book for a list of medications that require CC. PREVENTIVE SERVICES DD. RECONSTRUCTIVE SURGERY AND SERVICES EE. SERVICES TO DIAGNOSE INFERTILITY FF. TELEMEDICINE SERVICES GG. TRANSPLANTS - ORGAN - TISSUE - BONE MARROW TRANSPLANTS AND STEM CELL PROCEDURES HH. TRANSPLANT TRAVEL AND LODGING 7

II. URGENT CARE JJ. VISION EXAMS (ROUTINE) KK. PEDIATRIC CONTACT LENS FIT AND FOLLOW UP LL. PEDIATRIC EYEWEAR (EYEGLASSES OR CONTACT LENSES) MM. PEDIATRIC LOW VISION EVALUATION AND FOLLOW UP NN. PEDIATRIC LOW VISION HARDWARE OO. PEDIATRIC DENTAL 8

Multi-language Interpreter Services 9

Blue Cross Blue Shield of Arizona (BCBSAZ) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BCBSAZ provides appropriate free aids and services, such as qualified interpreters and written information in other formats, to people with disabilities to communicate effectively with us. BCBSAZ also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call 602-864-4884 for Spanish and 877-475-4799 for all other languages and other aids and services. If you believe that BCBSAZ has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: BCBSAZ s Civil Rights Coordinator, Attn: Civil Rights Coordinator, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, 602-864-2288, TTY/TDD 602-864-4823, crc@azblue.com. You can file a grievance in person or by mail or email. If you need help filing a grievance, BCBSAZ s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800- 368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 10