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Pre-Certification Requirements
Here is a general overview of the types of services that require pre-certification.
Please note: While some groups require pre-certification for all of these services, others only require pre-certification for a portion of the outpatient services listed or none at all. Pre-certification requirements may vary from group to group or by health plan.
The Authorization/Pre-Certification/Referral function in My Insurance Manager automatically determines if a member's benefits structure requires pre-certification and will let you know if you need to submit a pre-certification request for the selected service.
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Services that Generally Require Pre-certification
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- Behavioral health services, including substance abuse treatment
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- DME over specified dollar amounts (varies)
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- Investigational or experimental procedures¹
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- Elective inpatient procedures
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- Any procedure that may potentially be considered cosmetic in nature, such as blepheroplasty, reduction mammoplasty or TMJ
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- A one-time notification when a member is initiating outpatient chemotherapy or radiation therapy
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| ¹ Any drugs, services, treatment or supplies the BlueCross medical staff determines, with appropriate consultation, to be experimental, investigational or unproven are not covered services. Most CT scans, MRIs, MRAs and PET scans do not require pre-certification, but we will not reimburse for services deemed to be investigational. For example, CT coronary angiography and CT scans of the chest for lung cancer screening are investigational. For further information, please refer to our Medical Policies. For questions about particular procedures, please use the Contact Us link in the Medical Policies section. |
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