Precertification Requirement Grids

BCBSAZ Precertification Requirements *

Page 1

Banner Health HSA

Page 2

City of Glendale/City of Globe

Page 3

City of Mesa

Page 4

City of Phoenix

Page 5

Fort Mojave Indian Tribe

Page 6

Snell & Wilmer

Page 7

Gila River Gaming

Page 8

FEP

Page 9

*Refer also to the Alpha Prefix Grid for Large Group Alpha Prefixes. Groups on this list have precertification requirements in the PPO(A) column on page 1 unless otherwise specified.

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, waivers and pre-existing conditions, 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 managed 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.

Rev. 02/20/14

Blue Cross Blue Shield of Arizona Precertification Requirements Provider Assistance (602) 864-4320 or (800) 232-2345, option 4 Out-of-State Provider Precertification Requests (800) 676-2583 Rev. 01/09/14

Product Type X = Requires Precertification 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. These groups have precert requirements in column PPO (A), unless otherwise specified.

Custom 100+

Indemnity

PXD KTO

XBC XBF

X (2) X (2,5) X

X (2) X (2,5) X

X

X

X

X (5) X X (4) X X (5) X X X (6) X

X (5) X X (4)

X (5) X X (4)

HMO

PPO (A)

PPO (B)

XBG XBH XBK

XBB XBM XBP XBR

XBA XBE XBF XBG XBI XBJ XBY

(1)

(2,3)

X (1,5) X

X (2,3,5) X

X (5) X X

X

X

X (5) X X (4)

X (3,5) X X (4)

Procedure/Service Autism - Behavioral Therapy for Autism Spectrum Disorder (ASD) Behavioral & Mental Health services – Scheduled IP admissions only Clinical Trials Cochlear Implants Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Home Infusion Care (for certain medications only) Home Health visits (Skilled nurse visits) Inpatient Admission – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions. Long Term Acute Care (LTAC) Major Organ & Bone Marrow Transplants & Stem Cell procedures

X X X (5) (5) (5) X X X X X X X X X (6) (6) Out-of-Network Provider X X X X Skilled Nursing Facility (SNF) 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 X Phone: (800) 850-9122 BCBSAZ Specialty Pharmacy (Click here)* X X X Phone: (602) 864-4320 or (800) 232-2345 Option 4 BCBSAZ Retail & Mail Order RX Meds (Click here)* X X X Phone: (866) 325-1794 Pharmacy Benefits Manager X Retail & Mail Order Rx Meds. Phone: (866) 391-2370 No precertification is required for outpatient services, unless otherwise specified. 1)

2) 3) 4) 5) 6)

X (1,5) X X

For HMO product lines (XBG, 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. Some PPO plans provide behavioral health benefits through both the BSA and the BCBSAZ network. For benefits through the BSA, call (800) 2242125. Services are excluded from coverage for Blue Solutions. 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. Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity and pre-term labor.) 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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Blue Cross Blue Shield of Arizona Custom Precertification Requirements for Banner Health HSA #50000

Provider Assistance (602) 864-4320 or (800) 232-2345, option 4 Out-of-state Provider Precertification Requests (800) 676-2583 Rev. 01/09/14

X = Requires Precertification

Banner Health HSA Alpha Prefix = PPO

BNE

Procedures/Services Behavioral & Mental Health services

(1)

Clinical Trials

X

Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services Infertility

X

Inpatient Admission – Scheduled IP admissions only Long Term Acute Care (LTAC)

X X X (2) X

(3) Major Organ, Tissue or Bone Marrow Transplants & Stem Cell procedures Out-of-Network Provider X Covered when In-Network provider unavailable X Skilled Nursing Facility (SNF) 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 X Phone: (800) 900-6337 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.

3)

Optum (888)321-0881.

2

Blue Cross Blue Shield of Arizona Custom Precertification Requirements for City of Glendale and City of Globe Provider Assistance (602) 864-4320 or (800) 232-2345, option 4 Out-of-State Provider Precertification Requests (800) 676-2583 Rev. 01/01/14

X = Requires Precertification Alpha Prefix

City of Glendale PPO = XBP HMO = XBH

City of Globe HMO = XBK

Procedure / Service Autism - Behavioral Therapy for Autism Spectrum Disorder (ASD) Behavioral & Mental Health services – Scheduled IP admissions only Cancer Clinical Trials Dental related facility services, or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Home Health Care & Home Infusion services (for certain medications only) Inpatient Admission – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions. Long Term Acute Care (LTAC) Major Organ & Bone Marrow Transplants & Stem Cell procedures

X (1,2) X (1,2,5) X

X (1) X (1,5) X

X

X

X (5) X X (3) X (5) X X X

X (5) X X (3) X (5) X X

X X X (4) Out-of-Network Provider X X Skilled Nursing Facility (SNF) Pharmacy Benefit & Precertification Requirements / Lists Click on the appropriate link below to view the list of the medications that require precertification. BCBSAZ Specialty Self- Injectable Benefit (Click Here) X X Phone: (602) 864-4320, (800) 232-2345 Option 4 BCBSAZ Retail & Mail Order RX Meds (Click here) X X Phone: (866) 325-1794. No precertification is required for outpatient services, unless otherwise noted above. MRI / MRA / CT / PET Scans (outpatient facility)

1)

2) 3)

4)

5)

(HMO only)

For HMO product lines (XBH & XBK), the behavioral services administrator (BSA) is the exclusive provider to precertify and manage behavioral 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. PPO plans provide behavioral health benefits through both the BSA and the BCBSAZ network. For benefits through the BSA, call (800) 224-2125. Certain medications provided under the home health/home infusion benefit require precertification. A complete 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. 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. Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor).

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Blue Cross Blue Shield of Arizona Customer Precertification Requirements for City of Mesa Out-of-State Members Precertification - Arizona Foundation (AFMC) - (800) 624-4277 Eligibility and Benefits – BlueCard Eligibility Line – (800) 676-BLUE (2583) Rev. 01/01/14

City of Mesa Out of State Members

X = Requires Precertification Alpha Prefix

Procedure / Service Ambulance, excluding 911 initiated emergency transport Bariatric Surgery (Weight Management) Behavioral & Mental Health services - Inpatient and intensive outpatient Botox for medical conditions BRCA genetic services Cancer Clinical Trials Cardiac Rehabilitation – Inpatient only Chiropractic Care (after 25 visits only) Cochlear Implants Cosmetic /Experimental/Investigative services Detoxification (Urgent and Scheduled IP admissions) DME/Prosthetics with a cost > $1000 Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Home Health Care & Home Infusion services (including Private Duty Nursing) Hospice Inpatient Admission – ALL elective admissions, excluding maternity Long Term Acute Care (LTAC) Major Organ & Bone Marrow Transplants & Stem Cell procedures Newborn stays beyond the mother Out-of-Network Provider Outpatient Surgery in a free-standing or hospital-based surgery center/facility Outpatient Therapies – Physical, Occupational & Speech Pain Management treatments Skilled Nursing Facility (SNF) Sleep Studies Surgical or invasive procedure performed in a physician’s office if total cost >$500 Testosterone Treatments (pellets or shots) Pharmacy Benefit & Precertification Requirements / Lists

PPO = MDK

X X X X X X X X X X X X X X X X (1) X X X X (2) X X X X X X X

Certain injectable drugs are classified as “specialty self-injectable medications”. Precertification is required depending on the place of service.

Specialty Self-Injectable Arizona Foundation for Medical Care (AFMC) Phone: (800) 624-4277 CVS/Caremark Phone: (855) 264-5048

X X

Synagis - injections for RSV 1)

Notification to Arizona Foundation (800) 624-4277 within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor).

2)

PPO benefit plans have an out-of-network benefit, however, when there is not a PPO network specialist or facility available, Arizona Foundation for Medical care (AFMC) may, prior to delivery of services, pre-certify the member for the in-network coinsurance and deductible. The precertification request for this may be initiated by the referring or treating provider.

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Blue Cross Blue Shield of Arizona Custom Precertification Requirements for City of Phoenix Provider Assistance (602) 864-4320 or (800) 232-2345, option 4 Out-of-state Provider Precertification Requests (800) 676-2583 Rev. 01/09/14

X = Requires Precertification

City of Phoenix Alpha Prefix – PPO (Blue Preferred, Blue Preferred Saver) Alpha Prefix – HMO (Blue Choice)

PXO XBO

Procedures/Services Autism - Behavioral therapy for Autism Spectrum Disorder (ASD) Behavioral & Mental Health services – Inpatient & intensive outpatient Cancer Clinical Trials Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services Home Health Care & Home Infusion services Inpatient Admissions – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions. Intensive OP Programs – Chemical Dependency or Behavioral Health Long Term Acute Care (LTAC) Major Organ, Tissue or Bone Marrow Transplants & Stem Cell procedures MRA / MRI / PET Scans (outpatient facility)

X (1) X (1) (HMO only)

X X (2) X X X (1,2) X (1) X X X (HMO only)

X (3) X

Out-of-Network Provider

(HMO only) Outpatient Behavioral Health services Outpatient Therapies – Physical, Occupational & Speech (over 60 visits combined) X X Skilled Nursing Facility (SNF) 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 X Cigna Specialty Pharmacy: (800) 351-3606 Cigna Home Delivery: (Mail Order) (800) 835-3784 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. X Phone: (602) 864-4320, (800) 232-2345 Option 4 BCBSAZ Retail & Mail Order RX Meds (Click here) for the list of medications that require precertification. X Phone: (866) 325-1794

1) 2) 3)

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. Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.) 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.

5

Blue Cross Blue Shield of Arizona Custom Precertification Requirements for Fort Mojave Indian Tribe Provider Assistance (602) 864-4320 or (800) 232-2345, option 4 Out-of-State Provider Precertification Requests (800) 676-2583

. Eff. 01/01/14

X = Requires Precertification

Ft. Mojave Alpha Prefix

XBX

Procedure / Service Behavioral & Mental Health services – Scheduled IP admissions only Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (non-emergency only) Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services Home Infusion services (for certain medications only) Inpatient Admission – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions. Long Term Acute Care (LTAC) Major Organ & Bone Marrow Transplants & Stem Cell procedures

X (1) X X (1) X X (2) X (1) X X X (3) X

Out-of-Network Provider Skilled Nursing Facility (SNF) 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 X Phone: (800) 850-9122 Pharmacy Benefits Manager - Retail & Mail Order Rx Meds X Phone: (866) 391-2370 No precertification is required for outpatient services, unless otherwise specified. 1) Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.) 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) EPO benefit plans do not have an out-of-network benefit other than for emergency services.

6

Blue Cross Blue Shield of Arizona Custom Precertification Requirements for Snell & Wilmer Provider Assistance (602) 864-4320 or (800) 232-2345, option 4 Out-of-State Provider Precertification Requests (800) 676-2583

. Rev. 01/09/14

X = Requires Precertification Alpha Prefix- PPO & HSA

Snell & Wilmer SWB

Procedure / Service Behavioral & Mental Health services & Substance Use disorders – Scheduled IP admissions only Cancer Clinical Trials Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (non-emergency only) Durable Medical Equipment/Prosthetics (for rental/purchase price >$1500) Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services Home Infusion services (for certain medications only) Home Health visits (Skilled Nurse visits, PT, OT, ST) Inpatient Admission – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions. Long Term Acute Care (LTAC) Major Organ & Bone Marrow Transplants & Stem Cell procedures Out-of-Network Provider Skilled Nursing Facility (SNF)

X (1) X X X (1) X X X (2) X X (1) X X X (3) X

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

BCBSAZ Retail & Mail Order RX Meds (Click here) Phone: (866) 325-1794

X

No precertification is required for outpatient services, unless otherwise specified. 1)

Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.)

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.

7

Blue Cross Blue Shield of Arizona Custom Precertification Requirements for Gila River Gaming Provider Assistance (602) 864-4320 or (800) 232-2345, option 4 Out-of-State Provider Precertification Requests (800) 676-2583

. Eff. 01/01/14

Gila River Gaming

X = Requires Precertification Alpha Prefix

GLK

Procedure / Service Bariatric Surgery (includes Ambulatory Surgery Center) Behavioral & Mental Health services & Substance Use disorders – Scheduled IP admissions only Extended Active Rehabilitation (EAR) – Inpatient Rehabilitation services Home Infusion services (for certain medications only) Inpatient Admission – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions. Long Term Acute Care (LTAC) Major Organ & Bone Marrow Transplants & Stem Cell procedures Out-of-Network Provider Skilled Nursing Facility (SNF)

X X (1) X X (2) X (1) X X X X

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 (2) X (2)

BCBSAZ Retail & Mail Order RX Meds (Click here) Phone: (866) 325-1794

No precertification is required for outpatient services, unless otherwise noted above.

1)

Notification within 48 hours following admission is required for all medical and behavioral health emergent/urgent inpatient admissions (including maternity & pre-term labor.)

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.

8

Blue Cross Blue Shield of Arizona 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. 01/01/14

Federal Employee Program

X = Requires Precertification/Prior Approval Alpha Prefix

R

Procedures / Service Clinical Trials (for certain organ/tissue transplants) Dental related facility services or Dental related services integral to medical services when scheduled as an inpatient admission Detoxification (Urgent & Scheduled IP admissions) Extended Active Rehabilitation (EAR) - Inpatient Rehabilitation services

(1)

Emergency Admission – notify within 2 business days following the day of ER admission (Notify BCBSAZ even if the patient has been discharged) Hospice Inpatient Admission – Scheduled IP admissions only Includes medical, surgical & psychiatric admissions.  Maternity admission stays > 48 hrs. post vaginal delivery and > 96 hrs. post C-section  Newborn Stays for additional days Long Term Acute Care (LTAC)

X

Major Organ & Blood or Marrow Transplants (BMT) & Stem Cell procedures 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 Outpatient Intensity - Modulated Radiation Therapy (IMRT) for certain diagnoses Skilled Nursing Facility (SNF)

X X X

X X (2) (3) X X (4) X X (5) (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 X Phone: (877) 727-3784 Hours: 7 a.m. and 9 p.m. Eastern Time, Monday - Friday 1) 2) 3)

4)

5) 6)

For clinical trials for certain organ/tissue transplants, contact the FEP organ transplant line at (602) 864-4051. Refer to the 2014 Service Benefit Plan brochure (RI 71-005), online at fepblue.org. 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. 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. 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 68 through 75 in the 2014 Service Benefit Plan brochure (RI 71-005) for details on the transplant benefits and that all the requirements are met. Prior approval is not required for IMRT related to the treatment of head, neck, breast, or prostate cancer. The Federal Employee Program does not have a SNF benefit, except as outlined in the Service Benefit Plan brochure (RI 71005) accessible online at fepblue.org; however a flexible benefits option may be available.

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