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Certifications and Reviews

Services that Require Precertification

The following medical services routinely require precertification for the majority of Blue Cross and Blue Shield of Alabama members. Please check member eligibility and benefits with each patient encounter to verify applicability to your patient. In addition to the below, other services such as physical therapy, occupational therapy, speech therapy, chiropractic services, home health, hospice services, and private duty nursing may also require precertification. Please check member benefits to verify specific services requiring precertification.

Precertification Forms

Special Group Requirements

The below groups have additional medical or mental health precertification requirements. In order to ensure the most accurate information at the time of the service, please check all member benefits with each patient encounter.

FEP Behavioral Health Precertifications

FEP Behavioral Health Precertifications have specialized requirements based on the benefits chosen by the member. All inpatient stays require a precertification. Outpatient services to include partial hospitalization and intensive outpatient treatment require prior approval. A treatment plan is needed from each provider and for each new year. If additional visits are needed, a precertification is required.

The following applies to precertifications for FEP Behavioral Health:

Preadmission certification

Preadmission certification is a process that requires a member with coverage through Blue Cross and Blue Shield of Alabama to receive authorization for inpatient hospital admissions. This benefit, when applicable on group coverage, requires that scheduled/planned admissions be certified prior to the admission. Urgent/emergency admissions require certification within 48 to72 hours of the admission.

Note: Not all precertifications for groups with Blue Cross and Blue Shield of Alabama coverage are handled by Blue Cross and Blue Shield of Alabama. If another company handles the precertification, follow the instructions given by that company. This information may be found by checking your patients insurance card and their benefits online.

Types of Services That Do Not Routinely Require Precertification

Other Types of Certifications and Reviews

Please do not fax photographs or x-rays. Mail them to Medical Review, Post Office Box 362025, Birmingham, AL 35236. Write “DO NOT OPEN IN MAILROOM” on the front of the envelope.

All predeterminations must include the contract number, patient’s name and age, proposed procedure code, provider’s plan code and provider number. A decision on a predetermination is valid for one year from the date of the decision. A predetermination does not fulfill any contract pre-admission certification (PAC) requirements.

Surgical Procedures considered reconstructive verses cosmetic must be submitted with original photographs. Faxed copies are not accepted.

Outpatient Precertifications

Generally, outpatient services do not require precertification. However, should precertification be required, that information will be reflected in Blue Cross Online (BCOL). You may locate that information under headings such as:

<Exception Procedure Processing>
<Preadmission Certification>
<Surgery>
<X-rays and Labs>

Please refer to our web site, www.bcbsal.com, for specific information about Blue Cross and Blue Shield of Alabama coverage guidelines for a particular procedure or technology. The steps to view coverage guidelines are:

If BCOL indicates that precertification is required and there is no specific telephone number listed to obtain precertification and the facility is a concurrent utilization review participating (CURP) facility and the customer has Preferred Medical Doctor (PMD) benefits, then the facility is responsible for the precertification. The facility will use guidelines for precertification as per Blue Cross and Blue Shield
of Alabama Health Management instructions. Currently, these guidelines are InterQual® criteria.

If there is a telephone number listed on BCOL for precertification, the provider must call that number to obtain precertification. In this situation, Blue Cross may not be the third party administering this part of the customer’s health benefit plan. For example, State of Alabama contracts require precertification via IntraCorp. Authorization numbers given by IntraCorp are transmitted to Blue Cross daily. Once providers have that authorization number from IntraCorp, there is no need to make an additional telephone call to Blue Cross Customer Service to provide or verify that number.

Most secondary Blue Cross contracts do not require certification. BellSouth secondary contracts do require precertification.

Should precertification questions arise, providers may call 205-988-2245 or 1-800-248-2342. You may also reach the Medical Review area by fax at 205-220-9560 or e-mail MedicalReview@bcbsal.org.

Last Updated March 2010