2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 19
Section 3. How You Get Care
Page 19
- the day your benefits from your former plan run out; or
- the 92nd day after you become a member of this Plan, whichever happens first
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.
You need prior Plan approval for certain services
The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for Other services (called prior approval) are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us before you receive medical care or services. In other words, a pre-service claim for benefits may require precertification and prior approval. If you do not obtain precertification or prior approval as required, there may be a reduction or denial of benefits. Be sure to read all of the precertification and prior approval information below and on pages 20-22. Our FEP medical policies may be found by visiting www.fepblue.org/policies.
The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for Other services (called prior approval) are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us before you receive medical care or services. In other words, a pre-service claim for benefits may require precertification and prior approval. If you do not obtain precertification or prior approval as required, there may be a reduction or denial of benefits. Be sure to read all of the precertification and prior approval information below and on pages 20-22. Our FEP medical policies may be found by visiting www.fepblue.org/policies.
- Inpatient hospital admission, inpatient residential treatment center admission
In most cases, your physician or facility will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician, hospital or inpatient residential treatment center whether or not they have contacted us and provided all necessary information. You may also contact us at the phone number on the back of your ID card to ask if we have received the request for precertification. You are also responsible for enrolling in case management and working with your case manager if your care involves residential treatment. For information about precertification of an emergency inpatient hospital admission, please see page 26.
Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.
Warning:
We will reduce our benefits for the inpatient hospital stay by $500, even if you have obtained prior approval for the service or procedure being performed during the stay, if no one contacts us for precertification. If the stay is not medically necessary, we will not provide benefits for inpatient hospital room and board or inpatient physician care; we will only pay for covered medical services and supplies that are otherwise payable on an outpatient basis.
Note: If precertification was not obtained prior to admission, inpatient benefits (such as room and board) are not available for inpatient care at a residential treatment center. We will pay only for covered medical services and supplies that are otherwise payable on an outpatient basis.
Exceptions:
You do not need precertification in these cases:
You are admitted to a hospital outside the United States; with the exception of admissions for gender affirming surgery and admissions to residential treatment centers.
Note: Special rules apply when Medicare or another payer is primary, see pages 23-24.
- Other services
- Gene Therapy and Cellular Immunotherapy, including Car-T and T-cell receptor therapy