A prior approval review determines medical necessity and considers Federal Employee Program (FEP) benefits before a treatment, procedure, service, or supply is provided. FEP Standard and Basic Option plans require a prior approval for the procedures listed below.
Procedures Requiring Prior Approval for FEP Members
- Outpatient sleep studies performed outside the home - Required for sleep studies performed in a provider’s office, sleep center, clinic, outpatient center, hospital, skilled nursing facility, residential treatment center and any other location that is not the member’s home.
- Applied behavior analysis (ABA) - Required for ABA and all related services, including assessments, evaluations, and treatments. For more detail, refer to the medical policy .
- Gender reassignment surgery - Prior to surgical treatment of gender dysphoria, a treatment plan must be submitted that includes all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and the plan is later modified. See pages 68-69 of the 2017 Service Benefit Plan Brochure for additional information.
- BRCA Testing - Required for both preventative and diagnostic testing.
- Outpatient surgical services - The surgical services listed below require prior approval when they are to be performed on an outpatient basis. This requirement applies to both the physician and facility services.
- Outpatient surgery for morbid obesity - See the Service Benefit Plan brochure at www.fepblue.org for specific pre-surgical criteria that must be met.
- Outpatient surgical correction of congenital anomalies
- Outpatient surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth
Outpatient intensity-modulated radiation therapy (IMRT) - Required for all outpatient IMRT services except IMRT related to the treatment of head, neck, breast, or prostate cancer. Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT treatment of brain cancer.
Hospice care - Includes home hospice, continuous home hospice, or inpatient hospice care services.
- Organ/tissue transplants - See the Service Benefit Plan brochure at www.fepblue.org for the list of covered organ/tissue transplants. Prior approval is required for both the procedure and the facility. Prior approval is also required for travel benefits associated with a Blue Distinction Center for Transplants facility approval.
- Clinical trials for certain organ/tissue transplants - Contact our Transplant Clinical Trials Information Unit at 800-225-2268 for information or to request prior approval.
- Prescription drugs - Certain prescription drugs under our Retail or Mail Order Pharmacy programs require prior approval. Contact our Retail Pharmacy Program at 800-624-5060 to request prior approval or to obtain an updated list of prescription drugs that require prior approval. Note: Updates to the list of drugs and supplies requiring prior approval are made periodically during the year.
Include applicable diagnoses, procedure codes, and medical information with your prior approval request form. Prior approvals are usually valid for six months, as long as the patient's benefits do not change between the date the approval is given and the date the service is provided.
You will receive a written response within 15 calendar days of receipt of the request.
To request a review of medical necessity and FEP benefits:
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