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Pre-Service Review (Precertification/Predetermination)
Online Precertification
Precertification may be required for the services listed below. Go to your local Blue Plan's provider portal to see if precertification is required for these services for out-of-area members. Contact your local Blue Plan for more information on how to access this functionality in your local provider portal.
Note: Before providing services, always check patient eligibility and benefits through your local Blue Plan provider portal or your practice management system. Precertification requirements are subject to change at any time so you should verify benefits for the specific date of service for the service or equipment you will be providing.
Inpatient Services
Medical/Surgical
- Acute hospitalization
- Hospice care
- Long-term acute care hospital (LTACH)
- Rehabilitation services
Mental Health and Substance Use Disorders
- All non-emergency hospital admissions
- Includes inpatient residential treatment programs
- Excludes mental health and substance use disorder emergency services
- Detoxification services
- Procedure codes requiring precertification: H0008, H0009, H0010, H0011, H0012, H0013, H0014
Outpatient Services
Medical/Surgical
- Advanced imaging
- Genetic laboratory testing
- Home health services
- Hospice care
- Provider-administered drugs
- Radiation therapy management
- Select outpatient/office services
Mental Health and Substance Use Disorders
- Intensive Outpatient Programs (IOP)
- Procedure codes requiring precertification: 905, 906
- Partial Hospitalization Programs (PHP)
- Procedure codes requiring precertification: 912, 913
Precertification via Fax/Phone/Mail
Precertification is required for the following services and must be requested by fax, phone or mail:
- Home health
- Hospice
- Inpatient hospital
- Long-term acute care
Use the forms below to request precertification for these services or call the appropriate toll-free number:
- 1-833-663-8703: Other services, including peer-to-peer consultations
Predetermination
Courtesy predetermination will be provided for the services linked below when performed in an outpatient setting. Precertification is required if performed in an inpatient setting.