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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.
]