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Blue Cross "Preauthorization Schedule" - (12/28/2015)
It is imperative that participants enrolled in Empire Blue Cross Blue Shield be aware of the following “Preauthorization Schedule” found in the Empire Blue Cross Blue Shield, October 1, 2015 Certificate of Coverage booklet:
Preauthorization Schedule
Services Subject to Preauthorization Empire Blue Cross Blue Shield Preauthorization is required before you receive certain Covered Services. You are responsible for requesting Preauthorization for the following services:
- All inpatient admissions, including maternity admissions and admissions for illness or injury to newborns;
- Inpatient Mental Health Care, Substance Abuse Care and Alcohol Detoxification;
- Skilled Nursing Facility;
- Outpatient/Ambulatory “Surgical Treatments (certain procedures);
- Chiropractic Care (after the 5th visit);
- Physical, Occupational, Vision, and speech Therapy;
- Outpatient Cardiac Rehabilitation Therapy;
- Diagnostics;
- Outpatient Treatments;
- Air Ambulance;
- High tech radiology services: MRI, MRA, PET, CAT, Nuclear Technology services;
- Durable Medical Equipment;
- Prosthetics and Orthotics; Assistive communication Devices
Preauthorization/Notification Procedure If you seek coverage for services that require Preauthorization or notification, you or your provider must call Empire Blue Cross Blue Shield or our vendor at the number indicated on your ID card. You or your provider must contact Empire Blue Cross Blue Shield to request Preauthorization as follows:
- At least two (2) weeks prior to a planned admission or surgery when your provider recommends inpatient hospitalization. If that is not possible, then as soon as reasonably possible during regular business hours prior to the admission.
- At least two (2) weeks prior to ambulatory surgery or any ambulatory care procedure when your provider recommends the surgery or procedure be performed in an ambulatory surgical unit of a hospital or in an ambulatory surgical center.
- Within the first three (3) months of a pregnancy, or as soon as reasonably possible and again within 48 hours after the actual delivery date if your hospital stay is expected to extend beyond 48 hours for a vaginal birth or 96 hours for Cesarean birth.
- Before air ambulance services are rendered for a non-emergency condition.
You must contact Empire Blue Cross Blue Shield to provide notification as follows:
- As soon as reasonably possible when air ambulance services are rendered for an emergency condition
- If you are hospitalized in cases of an emergency condition, you must call Empire Blue Cross Blue Shield within 48 hours after your admission or as soon thereafter as reasonably possible.
After receiving a request for approval, Empire Blue Cross Blue Shield will review the reasons for your planned treatment and determine if benefits are available. Criteria will be based on multiple sources which may include medical policy, clinical guidelines and pharmacy and therapeutic guidelines.
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