Pre-authorization:
This is a requirement to be adhered to before the patient gets registered for treatment. Also known as pre-certification, this requires notification to the plan of certain planned services and all elective inpatient hospitalizations before they are rendered. Depending on the plan, either the patient or the provider must seek pre-authorization for these services. Certain managed care plans require the patients to go through a contracted physician participating in their network. If the patient gets treated through a physician not part of the network then the managed care plan require the physician to call the plan and notify them of the treatment before hand. Only after their approval can the treatment be proceeded. If the treatment is done without the approval, then the managed care plan will not reimburse the physician for their services nor can the physician bill the patient. This approval is called pre-authorization and a copy of this should be made available in the patient’s file before the treatment is rendered. Another requirement is to obtain a second opinion from an impartial physician regarding medical necessity of the procedure to be performed.
A service is deemed medically necessary when-
• It is appropriate for the diagnosis being reported.
• It is provided in the appropriate location.
• It is not provided for the patient’s or his/ her family’s convenience.
• It is not custodial care. (Custodial care is care that can be provided by people who are not trained medical professionals.)
Once the authorization has been granted, an authorization # would be given. This number should be reported on the claim for the service.
Preauthorization Requirements
Preauthorization establishes in advance the Medical Necessity or Experimental/Investigational nature of certain care and services covered under this Plan. It ensures that the Preauthorized care and services described below will not be denied on the basis of Medical Necessity or Experimental/Investigational. However, Preauthorization does not guarantee payment of benefits. Actual availability of benefits is always subject to other requirements of the Plan, such as Preexisting Conditions, limitations and exclusions, payment of premium, and eligibility at the time care and services are provided.
The following types of services require Preauthorization:
• All inpatient Hospital Admissions,
• Extended Care Expense,
• Home Infusion Therapy,
• All inpatient treatment of Chemical Dependency, Serious Mental Illness, and Mental Health Care,
• If you transfer to another facility or to or from a specialty unit within the facility.
• The following outpatient treatment of Chemical Dependency, Serious Mental Illness, and Mental Health Care:
– Psychological testing;
– Neuropsychological testing;
– Electroconvulsive therapy;
– Intensive Outpatient Program.
Intensive Outpatient Program means a freestanding or Hospital-based program that provides services for at least three hours per day, two or more days per week, to treat mental illness, drug addiction, substance abuse or alcoholism, or specializes in the treatment of co-occurring mental illness with drug addiction, substance abuse or alcoholism. These programs offer integrated and aligned assessment, treatment and discharge planning services for treatment of severe or complex co-occurring conditions which make it unlikely that the Participants will benefit from programs that focus solely on mental illness conditions.
You are responsible for satisfying Preauthorization requirements. This means that you must ensure that you, your family member, your Physician, Behavioral Health Practitioner or Provider of services must comply with the guidelines below. Failure to Preauthorize services will require additional steps and/or benefit reductions as described in the paragraph entitled Failure to Preauthorize.
Preauthorization for Inpatient Hospital Admissions
In the case of an elective inpatient Hospital Admission, the call for Preauthorization should be made at least two working days before you are admitted unless it would delay Emergency Care. In an emergency, Preauthorization should take place within two working days after admission, or as soon thereafter as reasonably possible.
To satisfy Preauthorization requirements, on business days between 7:30 a.m. and 6:00 p.m. Central Time, you, your Physician, Provider of services, or a family member should call one of the Customer Service toll-free numbers listed on the back of your Identification Card. After working hours or on weekends, please call the Medical Preauthorization Helpline toll-free number listed on the back of your Identification Card. Your call will be recorded and returned the next working day. A benefits management nurse will follow up with your Provider’s office. All timelines for Preauthorization requirements are provided in keeping with applicable state and federal regulations.
In-Network Benefits will be available if you use a Network Provider or Network Specialty Care Provider. If you elect to use Out-of-Network Providers for services and supplies available In-Network, Out-of-Network Benefits will be paid. In-Network and Out-of-Network Providers may Preauthorize services for you, when required, but it is your responsibility to ensure Preauthorization requirements are satisfied.
However, if care is not available from Network Providers as determined by BCBSTX, and BCBSTX authorizes your visit to an Out-of-Network Provider to be covered at the In-Network Benefit level prior to the visit, In-Network Benefits will be paid; otherwise, Out-of-Network Benefits will be paid.
When an inpatient Hospital Admission is Preauthorized, a length-of-stay is assigned. If you require a longer stay than was first Preauthorized, your Provider may seek an extension for the additional days. Benefits will not be available for room and board charges for medically unnecessary days.
Preauthorization not Required for Maternity Care and Treatment of Breast Cancer Unless Extension of Minimum Length of Stay Requested
Your Plan is required to provide a minimum length of stay in a Hospital facility for the following:
• Maternity Care
– 48 hours following an uncomplicated vaginal delivery
– 96 hours following an uncomplicated delivery by caesarean section
• Treatment of Breast Cancer
– 48 hours following a mastectomy
– 24 hours following a lymph node dissection
You or your Provider will not be required to obtain Preauthorization from BCBSTX for a length of stay less than 48 hours (or 96 hours) for Maternity Care or less than 48 hours (or 24 hours) for Treatment of Breast Cancer. If you require a longer stay, you or your Provider must seek an extension for the additional days by obtaining Preauthorization from BCBSTX.
Preauthorization for Extended Care Expense and Home Infusion Therapy
Preauthorization for Extended Care Expense and Home Infusion Therapy may be obtained by having the agency or facility providing the services contact BCBSTX to request Preauthorization. The request should be made:
• Prior to initiating Extended Care Expense or Home Infusion Therapy;
• When an extension of the initially Preauthorized service is required; and
• When the treatment plan is altered.
BCBSTX will review the information submitted prior to the start of Extended Care Expense or Home Infusion Therapy and will send a letter to you and the agency or facility confirming Preauthorization or denying benefits. If Extended Care Expense or Home Infusion Therapy is to take place in less than one week, the agency or facility should call the BCBSTX Medical Preauthorization Helpline telephone number indicated in this Benefit Booklet or shown on your Identification Card.
If BCBSTX has given notification that benefits for the treatment plan requested will be denied based on information submitted, claims will be denied.
Preauthorization for Chemical Dependency, Serious Mental Illness, and Mental Health Care
In order to receive maximum benefits, all inpatient treatment for Chemical Dependency, Serious Mental Illness, and Mental Health Care must be Preauthorized by the Plan. Preauthorization is also required for
certain outpatient services. Outpatient services requiring Preauthorization include psychological testing, neuropsychological testing, Intensive Outpatient Programs and electroconvulsive therapy. Preauthorization is not required for therapy visits to a Physician, Behavioral Health Practitioner and/or Professional Other Provider.
To satisfy Preauthorization requirements, you, a family member, or your Behavioral Health Practitioner must call the Mental Health/Chemical Dependency Preauthorization Helpline toll-free number indicated in this Benefit Booklet or shown on your Identification Card. The Mental Health/Chemical Dependency Preauthorization Helpline is available 24 hours a day, 7 days a week. All timelines for Preauthorization requirements are provided in keeping with applicable state and federal regulations.
In-Network Benefits will be available if you use a Network Provider or Network Specialty Care Provider. If you elect to use Out-of-Network Providers for services and supplies available In-Network, Out-of-Network Benefits will be paid. In-Network and Out-of-Network Providers may Preauthorize services for you, when required, but it is your responsibility to ensure Preauthorization requirements are satisfied.
However, if care is not available from Network Providers as determined by BCBSTX, and BCBSTX authorizes your visit to an Out-of-Network Provider to be covered at the In-Network Benefit level prior to the visit, In-Network Benefits will be paid; otherwise, Out-of Network Benefits will be paid.
When treatment or service is Preauthorized, a length-of-stay or length of service is assigned. If you require a longer stay or length of service than was first Preauthorized, your Behavioral Health Practitioner may seek an extension for the additional days or visits. Benefits will not be available for medically unnecessary treatment or services.
Failure to Preauthorize
If Preauthorization for inpatient Hospital Admissions, Extended Care Expense, Home Infusion Therapy, all inpatient and the above specified outpatient treatment of Chemical Dependency, Serious Mental Illness and Mental Health Care is not obtained:
• BCBSTX will review the Medical Necessity of your treatment or service prior to the final benefit determination.
• If BCBSTX determines the treatment or service is not Medically Necessary or is Experimental/Investigational, benefits will be reduced or denied.
• You may be responsible for a penalty in connection with the following Covered Services, if indicated on your Schedule of Coverage:
– Inpatient Hospital Admission
– Inpatient treatment of Chemical Dependency, Serious Mental Illness, or Mental Health Care.
The penalty charge will be deducted from any benefit payment which may be due for the Covered Services.
If an inpatient Hospital Admission, Extended Care Expense, Home Infusion Therapy, any treatment of Chemical Dependency, Serious Mental Illness, and Mental Health Care or extension for any treatment or service described above is not Preauthorized and it is determined that the treatment, service, or extension was not Medically Necessary or Experimental/Investigational, benefits will be reduced or denied.
