| Precertification Requirements List |
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Service
|
Precertification Requirements
|
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Inpatient Hospital Admissions
|
YES
|
|
Ambulance Services
|
YES - Air Ambulance only
|
|
Bone Mass Measurement
|
NO
|
|
Chiropractic Services
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NO
|
|
Colorectal Screening Exams
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NO
|
|
Diabetes Self Monitoring Training and Supplies
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NO
|
|
Doctor Office Visits (PCP or Specialist)
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NO
|
|
Durable Medical Equipment
|
YES > $2500
|
|
Emergency Care
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NO
|
|
Home Health Care/Home Infusion Therapy (HIT)
|
YES
|
|
Hospice Care
|
YES
|
|
Immunizations (Flu, Hepatitis B for At Risk and Pneumonia)
|
NO
|
|
Laboratory Services (Outpatient)
|
NO
|
|
Mammograms (Annual Screening 40+)
|
NO
|
|
Mental Health Care (Inpatient & Outpatient)
|
YES - All levels of care
|
|
Out-of-Network Services
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YES - If In-Network Benefit Level is Requested
|
|
Outpatient Services (Outpatient Facility Based Services not included on this list)
|
NO
|
|
Pap Smears and Pelvic Exams
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NO
|
|
Podiatry Sevices
|
NO
|
|
Prostate Cancer Screening Exams
|
NO
|
|
Prosthetic Devices
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YES > $2500
|
|
Radiology Services (Outpatient)
|
YES - High Tech Imaging Services only
|
|
Rehabilitation (Outpatient)
|
YES - Home Setting Only
|
|
Skilled Nursing (In a Medicare Certified Nursing Facility)
|
YES
|
|
Substance Abuse Care (Inpatient & Outpatient)
|
YES - All levels of care
|
For precertification, you can access iEXCHANGE Web or by calling the iEXCHANGE Interactive Voice Response (IVR) System at 1-800-413-0869.
For precertification of High Tech Imaging Services (CT/CTA scans, MRI/MRA scans, SPECT/Nuclear Cardiology studies and PET scans), call American Imaging Management (AIM) at 1-800-859-5299.
NOTE: Whether the services are Medically Necessary must be determined before a precertification number will be issued. Claims received that do not have a precertification number will be denied. Blue Medicare PPO Physicians/Professional Providers may not seek payment from the Member when a claim is denied for lack of a precertification number.
For additional information, please refer to the Blue Medicare PPO Supplement.
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