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Precertification requirements for FEP members for BRCA testing and outpatient services

December 30, 2014

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Effective January 1, 2015, BRCA (breast cancer gene) testing requires precertification for members who have coverage under the Federal Employee Program (FEP).

As previously communicated, the services listed below also now require precertification:

  • outpatient intensity-modulated radiation therapy (IMRT), except related to the treatment of head, neck, anal canal, anal, 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 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.

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 services for BRCA testing or outpatient services for FEP members, call Highmark Blue Shield, an independent company, at 1-866-763-3608.

As a reminder, precertification requests for inpatient and hospice services for FEP members will continue to be performed by Independence. 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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