Docstoc

CT Scans Requiring Precertification

Document Sample
CT Scans Requiring Precertification Powered By Docstoc
					BC Non-FPLIC Authorizations 10/01/2011
                                                BLUE CROSS (NON-FPLIC) PRECERTIFICATION REQUIREMENTS

Precertification determines medical necessity and is not a guarantee of payment. Payment is determined by the insured’s eligibility and benefits at the time of
service. Providers should check member eligibility and benefits prior to rendering the service.

Service Representatives – Traditional    1-888-827-7117
Service Representatives – PPO            1-866-262-5635
                                                                                                     1-800-638-0505 - Traditional
                                                                                                     1-866-262-5623 – PPO
Precertification is required:                                                                  Fax # 1-570-200-6788 (All Products)

       Prior to Inpatient admissions for specific primary/admitting diagnoses. (See list below)

       Prior to inpatient admissions to: Skilled Nursing Facilities, Rehabilitation Hospitals and all Non-participating Facilities.

       For all Transplant surgeries AND select surgical procedures when performed on day of admission. (See list below)

       For Home Health Services (except the visit following a mastectomy or maternity admission within time guideline

       For Inpatient Behavioral Health Services for the following ICD-9 diagnosis codes: 290 – 319 precert is required. (Call Community Behavioral Healthcare
        of Northeastern PA (CBHNP) at 1-800-577-3742). For Outpatient Services please call to verify precertification requirements.

       For Morbid Obesity surgery for the following codes. Patient must meet criteria before precertification is requested.
               ICD-9 Codes: 43.82, 44.31, 44.38, 44.39, 44.5,44.68, 44.69, 44.95 – 44.98
               CPT Codes:       43644, 43645, 43770 – 43775, 43842, 43843, 43845 – 43848, 43886 – 43888


Managed Pharmacy Program:             Fax # 1-570-200-6870               Phone # 1-800-722-4062

       Home Infusion Services - TPN, Enteral nutrition, IVIG, anti-infective therapy

       Refer to formulary for the current list of drugs requiring prior authorization – www.bcnepa.com
BC Non-FPLIC Authorizations 10/01/2011
                                                 BLUE CROSS (NON-FPLIC) PRECERTIFICATION REQUIREMENTS

1-800-638-0505 Traditional      1-866-262-5623 PPO 1-570-200-6788 Fax-All Products
Precertification is required for any of the following ICD-9 inpatient procedures, ONLY if performed on the day of admission:
Procedure Code                                 Description                                      Procedure Code                Description
00.51,00.54, 37.76 to 37.78, 37.94, 37.96 to   Pacemaker/AICD Defibrillators                    51.10                         ERCP
37.98, 39.64
00.55, 00.64, 00.65                            Renal/Femoral/Iliac Stents                       51.23, 51.24                  Laparoscopic Cholecystectomy
00.66                                          Percutaneous Transluminal Angioplasty (          53.00 to 53.05, 53.10 to      Herniorrhaphy (Inguinal) (femoral)
                                               PTCA)                                            53.31, 53.41, 53.42, 53.43,   (incisional or ventral) (Umbilical)
                                                                                                53.49, 53.51 to 53.69         (epigastric)
03.09, 03.6, 80.51, 84.60, 84.61               Laminectomy, Laminotomy, Discectomy              59.4 to 59.79, 78.69          Insertion or removal Uretheral
                                                                                                                              sling/suspension

06.02, 06.2, 06.3, 06.31, 06.39, 06.4, 06.5,   Operations on thyroid and parathyroid glands     60.29                         Prostatectomy (TURP)
06.50, 06.51, 06.52, 06.81, 06.89, 06.99
27.69                                          Palatopharyngoplasty                             68.31                         Hysterectomy, supracervical
33.21 to 33.24                                 Bronchoscopy                                     68.29, 69.19                  Laparoscopy, myomectomy
34.22, 34.25                                   Mediastinoscopy                                  68.51, 68.59                  Vaginal Hysterectomy
37.20, 37.26, 37.29                            EPS Studies                                      70.50 to 70.55                Anteroposterior colporrhaphy and
                                                                                                                              repair
37.34, 37.78                                   Cardiac Ablations                                70.50 to 70.55, 70.93         Cystocele/Rectocele Repairs
44.66, 44.67                                   Laparoscopic Fundoplication/Fundoplasty          79.0 to 79.09, 79.10 to       Closed Reduction of Fractures
                                                                                                79.19
45.13,45.16                                    EGD                                              83.63                         Rotator Cuff Repair
47.01                                          Laparoscopic appendectomy                        92.30 to 92.32                Stereotactic Computer Assisted
                                                                                                                              Volumetric Procedure

 Precertification is required for any of the following diagnoses ONLY if it is the primary or admitting diagnosis:
Description             Diagnosis Code                                                       Description                              Diagnosis Code
Abdominal Pain          789.0 – 789.07, 789.09                                               Hypertension                             401.0, 401.1, 401.9
Angina pectoris         413.0, 413.1, 413.9                                                  Labyrinthitis                            386.3 – 386.35
Atrial fibrillation and 427.31, 427.32                                                       Nausea & Vomiting                        787.0 - 787.03
flutter
Cellulitis              682.0 – 682.9                                                        Palpitations                             785.1
Chest pain              786.50, 786.51, 786.52, 786.59                                       Renal Colic/Kidney Stone                 592.0, 592.1, 592.9,
                                                                                                                                      788.0
Concussion             850.0, 850.9                                                           Syncope and collapse                    780.2
Diabetes Mellitus      250.0, 250.03, 250.9, 250.91, 250.93                                   TIA                                     435.9
Dizziness/Giddiness    780.4                                                                  Urinary Tract Infection                 599.0
Gastroenteritis        558.9                                                                  Volume Depletion/Dehydration            276.5, 276.50 – 276.52
Headache               307.81, 339.0 – 339.89, 346.0 – 346.93, 784.0                          Other specified cardiac dysrhythmias    427.89
Herniated disc, Lumbar Radiculopathy, Medical back pain         **Precertification is not required for these diagnosis codes if they are associated with the
Diagnosis Codes:− 722, 722.0, 722.1, 722.2, 722.7, 722.10,      following surgical codes:
722.11, 722.70, 722.71, 722.72, 722.73
723, 723.0                                                      03.39, 03.4, 03.59, 77.29, 77.39, 78.59, 81.3, 81.00, 81.02, 81.03, 81.04, 81.05, 81.06, 81.07,
724, 724.0, 724.1, 724.2, 724.3, 724.4, 724.5, 724.6, 724.00,   81.08, 81.30,81.31, 81.32, 81.33, 81.34, 81.35, 81.36, 81.37, 81.38, 81.39, 81.62, 81.63,
724.01, 724.02, 724.03, 724.09,729.2

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:5
posted:11/27/2011
language:English
pages:3