Federal Employee Program (FEP) medical authorizations
A prior approval, or PA, review determines medical necessity and considers FEP benefits before a treatment, procedure, service, or supply is provided. A prior approval is required for the procedures listed below for both the FEP Standard and Basic Option plan and the FEP Blue Focus plan.
If you have questions regarding the list, please contact the dedicated FEP Customer Service team at 800-532-1537. You may also view the prior approval information in the Service Benefit Plan Brochures.
To request a review of medical necessity and FEP benefits:
- View FEP medical policies
- View procedures requiring prior approval below and submit medical authorization
- View drugs in the Medical Benefit Prior Approval Drug List and submit a drug authorization
- If the drug/procedure/service is not found in the lists of procedures requiring prior approval below or the FEP medical prior authorization drug list, complete and fax the Federal Employee Program (FEP) Prior Approval form
- If the drug/procedure/service found in the lists of procedures requiring prior approval is for Applied Behavior Analysis for the Treatment of Autism, complete and fax the Applied Behavior Analysis for the Treatment of Autism (Pre-Service Inquiry)
Gene therapy and cellular immunotherapy – Required.
Air ambulance transport (non-emergent) – Transport related to immediate care of a medical emergency or accidental injury does not require prior approval.
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 details, refer to the medical policy.
Hearing aids – Prior approval is required to receive coverage for hearing aids.
Genetic testing – Required when the test is being performed to assess the risk of passing a genetic condition to a child, or when the member has no active disease or signs or symptoms of the disease that is being screened. Prior approval is not required when a member has an active disease, signs and symptoms of a genetic condition that could be passed to a child, or when the test is needed to determine a course of treatment for a disease.
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 — Performed on an inpatient or outpatient basis - are subject to the pre-surgical requirements listed in our medical policy.
- Outpatient surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth.
- Outpatient surgery elective non-urgent orthopedic procedures; hip, knee and spine when performed by Preferred, Participating/Member and Non-participating/Non-member professional and facility providers.
Proton beam therapy – Prior approval is required for all proton beam therapy services except for members aged 21 and younger, or when related to the treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; Hodgkin and non-Hodgkin lymphomas.
Stereotactic radiosurgery – Prior approval is required for all stereotactic radiosurgery except when related to the treatment of malignant neoplasms of the brain, and of the eye specific to the choroid and ciliary body; benign neoplasms of the cranial nerves, pituitary gland, aortic body, or paraganglia; neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations.
Stereotactic body radiation therapy
Reproductive Services and associated drugs – Prior approval is required for intracervical insemination (ICI), intrauterine insemination (IUI), intravaginal insemination (IVI), and assisted reproductive technologies (ART).
Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.
Hospice care – Inpatient hospice care services.
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 transplant facility approval. See the Standard and Basic Option Service Benefit Plan brochure for the list of covered organ/tissue transplants.
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 –
- Use the drug authorization table below to determine if you need an authorization.
- If you need an authorization, log in to submit a request.
Begin a drug authorization - Check the status of existing authorizations or to see if further action is needed.
Check your drug authorization
Medical foods covered under the pharmacy benefit – Required.
Include applicable diagnoses, procedure codes, and medical information with your prior approval request form. Prior approvals are usually valid for 90 days, 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.
Penalty Note: You must obtain prior approval for these services. Failure to obtain prior approval will result in a $100 penalty. Pre-certification is also required if the service or procedure requires an inpatient hospital admission.
Gene therapy and cellular immunotherapy – Required.
Air ambulance transport (non-emergent) – Transport related to immediate care of a medical emergency or accidental injury does not require prior approval.
Applied behavior analysis (ABA) – Required for ABA and all related services, including assessments, evaluations, and treatments. For more details, refer to the medical policy.
Cochlear implants – Required.
Genetic testing – Required when the test is being performed to assess the risk of passing a genetic condition to a child, or when the member has no active disease or signs or symptoms of the disease that is being screened. Prior approval is not required when a member has an active disease, signs and symptoms of a genetic condition that could be passed to a child, or when the test is needed to determine a course of treatment for a disease.
Radiology, high technology – All, including CT scan/MRIs/PET scan services.
Hospice care – Inpatient hospice care services.
Transplants – Required for all transplants, except cornea. See the FEP Blue Focus Service Benefit Plan brochure 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.
Oral and maxillofacial surgery – Prior approval is required, except when related to an accidental injury and provided within 72 hours of the accident.
Outpatient cardiac rehab – Required.
Outpatient residential treatment – Required for any condition.
Clinical trials for certain organ/tissue transplants – A transplant clinical trial may not be available for your condition. If you or your provider are considering a clinical trial, please contact us at the telephone number on the back of your FEP Blue Focus ID card for assistance in determining if a covered clinical trial is available in a covered facility.
Prescription drugs –
- Use the drug authorization table below to determine if you need an authorization.
- If you need an authorization, log in to submit a request.
Begin a drug authorization - Check the status of existing authorizations or to see if further action is needed.
Check your drug authorization
Prosthetic devices (external) and specialty DME – Includes but not limited to specialty hospital beds, deluxe wheelchairs, power wheelchairs, mobility devices including scooters, microprocessor limb prosthesis, electronic and externally powered prosthesis and related supplies.
Proton beam therapy – Prior approval is required for all proton beam therapy services except for members aged 21 and younger, or when related to the treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; Hodgkin and non-Hodgkin lymphomas.
Stereotactic radiosurgery – Prior approval is required for all stereotactic radiosurgery except when related to the treatment of malignant neoplasms of the brain and of the eye specific to the choroid and ciliary body; benign neoplasms of the cranial nerves, pituitary gland, aortic body, or paraganglia; neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations.
Stereotactic body radiation therapy
Reproductive services and associated drugs – Prior approval is required for intracervical insemination (ICI), intrauterine insemination (IUI), and intravaginal insemination (IVI).
Sperm/egg storage – Prior approval is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.
Pulmonary rehabilitation – Required.
Surgical services – See the FEP Blue Focus Service Benefit Plan brochure for details on the following surgeries:
- Morbid obesity — performed on an inpatient or outpatient basis – are subject to the pre-surgical requirements listed in our medical policy. Benefits are only available for the surgical treatment of severe obesity when provided at a Blue Distinction Specialty Care Center for Bariatric (weight loss) Surgery®.
- Oral maxillofacial
- Breast reduction / augmentation not related to treatment of cancer
- Reconstructive surgery for conditions other than breast cancer
- Orthognathic surgery procedures, bone grafts, osteotomies and surgical management temporomandibular joint (TMJ)
- Other — hip, knee, ankle, spine, shoulder, rhinoplasty, septoplasty, varicose vein, and all orthopedic procedures using computer-assisted musculoskeletal surgical intervention
Include applicable diagnoses, procedure codes, and medical information with your prior approval request form. Prior approvals are usually valid for 90 days, 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.
Disclaimer
Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. A Local Blue Plan may require additional criteria for providers located in its own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers’ need for affordable healthcare. Each provider’s cost of care is evaluated using data from its Local Blue Plan. Providers in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of care evaluation(s) must meet BDC+ national criteria. National criteria for BDC and BDC+ are displayed on www.bcbs.com. Individual outcomes may vary. For details on a provider’s in-network status or your own policy’s coverage, contact your Local Blue Plan and ask your provider before making an appointment. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for non-covered charges or other losses or damages resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers.