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Precertification requirements for outpatient services for FEP members

October 31, 2014

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For members who have coverage under the Federal Employee Program (FEP), the following services require precertification when performed on an outpatient basis:

  • outpatient intensity-modulated radiation therapy (IMRT), except related to the treatment of head, neck, breast, or prostate cancer (Note: Brain cancer is not considered a form of head or neck cancer; therefore, precertification is required for IMRT treatment of brain cancer.);
  • outpatient surgery for morbid obesity (refer to the Service Benefit Plan summary on the FEP website for specific pre-surgical criteria that must be met);
  • outpatient surgical correction of congenital anomalies;
  • outpatient surgery needed to correct accidental injuries to the jaw, cheeks, lips, tongue, and roof or floor of mouth.
These services must meet the requirements listed in the applicable FEP medical policies, which are available on the FEP website. Scroll to the bottom of the page and select Medical Policies.

To obtain precertification for outpatient services for FEP members, call Highmark Blue Shield, an independent company, at 1-866-763-3608. Failure to obtain precertification will result in a retrospective review to determine compliance with FEP medical policies. Should services be denied for lack of medical necessity, reimbursement will not be made and the member may not be billed.

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