Commercial Pre-authorization List

This Commercial Pre-authorization List includes services and supplies that require pre-authorization or notification for commercial plan products. Pre-authorization requirements on this page apply to our group, Individual, Administrative Services Only (ASO) and joint administration members.

Direct clinical information reviews (MCG Health)

For select CPT codes, Availity's electronic authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to Availity Essentials to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a request. View the services that may receive automated approval (PDF).

Joint administration members

Group #

Pre-authorization form

Fax

Phone

#70000000

1 (877) 955-3548

1 (866) 947-9522

#70000002

1 (855) 836-3884

1 (855) 778-9047

#70000003

(503) 654-8570

(503) 654-9447 or 1 (800) 862-3338

#70000004

1 (877) 955-3548

1 (855) 258-6451

#70000005

(503) 654-8570

(503) 654-9447 or 1 (800) 862-3338

#70000007

1 (877) 955-3548

1 (866) 504-6812

#70000008

1 (855) 540-1980

1 (855) 240-3696

#70000009

1 (866) 748-6573

1 (866) 955-1490

#70000010

1 (866) 748-6574

1 (877) 955-1570

#70000011

1 (877) 955-3548

1 (833) 951-1370

#70000012

(208) 955-1415

1 (888) 921-0366

(541) 516-1168

1 (800) 441-4518

#70000013

Submit pre-authorization requests to Regence. Note: Services authorized by vendors (e.g., AIM or eviCore) do not apply to these members.

See the How to submit a pre-authorization request or notification section above.

See the How to submit a pre-authorization request or notification section above.

#70000014

Not available.
Please call (877) 624-6219.

Outpatient fax: (516) 723-7306
Inpatient fax: (516) 723-7339

(877) 624-6219

Pre-authorization for out-of-area (BlueCard) members

Members of some group health plans may have terms of coverage or benefits that differ from the information presented here. Refer to the Important Pre-authorization Reminders section for details. To verify coverage or benefits or determine pre-certification or pre-authorization requirements for a particular member, call 1-800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.

Online

  • Use the Electronic Provider Access (EPA) tool available in the Availity Portal. With EPA, you can gain access to an out-of-area member's Home Plan provider portal, through a secure routing mechanism and have access to electronic pre-service review capabilities.
  • Use our online tool to be automatically routed to the home plan's pre-authorization / pre-certification requirements. Launch the tool.

Phone

Call BlueCard Eligibility at 1 (800) 676-BLUE (2583). You will be asked for the member's prefix and the type of service for which you are calling:

  • Medical/surgical
  • Behavioral health
  • Diagnostic imaging/radiology
  • Durable medical equipment (DME)

Upon making your selection, you will be connected to the appropriate Blue Plan.

Electronic inquiry

Submit an ANSI 278 transaction (referral/authorization) to Regence.

Important pre-authorization reminders

  1. Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
  2. Before requesting pre-authorization, please verify member eligibility and benefits via the Availity Portal as the member contract determines the covered benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  5. Medical policies, MCG and CMS criteria may be used as the basis for service coverage determinations, including length of stay and level of care. Visit MCG's website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of guidelines for specific services.
  6. Some member contracts have specific pre-authorization requirements. The member's contract language will apply.
  7. Emergency services do not require pre-authorization, but are subject to hospital admission notification requirements (see below).
  8. Please note that a pre-authorization does not guarantee payment for requested services. (See #2 above). Our reimbursement policies may affect how claims are reimbursed. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
  9. Investigational and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially investigational services and are subject to review. Please refer to the Clinical Edits by Code list for additional information. View a sample non-covered member consent form (PDF).
  10. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete requirements.

Payment implications for failure to pre-authorize services

Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.

Please note the following:

  • Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient.
  • If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any pre-authorization penalties for failure of the facility to provide the required inpatient admission and discharge notification.
  • A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be covered benefits and medically necessary.
  • If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility or provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.

Inpatient admissions

See below for chemical dependency and mental health admissions.

Habilitative inpatient services

  • Pre-authorization is required prior to patient admission.

Hospital admissions

  • Pre-authorization is required for elective inpatient admissions.
  • Notification of a hospital admission or discharge is necessary within 24 hours of admission or discharge (or one business day if the admission or discharge occurs on a weekend or a federal holiday). Effective January 1, 2023: Notification of hospital admission and discharge required within 24 hours, regardless of federal holidays or day of the week.
  • Notification is required via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.
  • Requests for concurrent medical necessity review must include diagnosis and clinical information regarding the member’s current inpatient stay. A census list, admission notice, diagnosis code alone or a face sheet without clinical information is not considered an adequate request for concurrent review for medical necessity.

Inpatient hospice

  • Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). Effective January 1, 2023: Notification of inpatient hospice admission and discharge required within 24 hours, regardless of federal holidays or day of the week.
  • Notification is required via fax. Learn more about this requirement.

Long-Term Acute Care Facility (LTAC)

  • Pre-authorization is required prior to patient admission.

Rehabilitation

  • Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

  • Pre-authorization is required prior to patient admission.

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • We require the facility to specifically notify us when ECMO is initiated on a Regence member. Subject to review.

Durable medical equipment

Bone Growth Stimulators, Electrical (Osteogenic Stimulation) (PDF)

  • E0747, E0748, E0749
  • Administrative services only (ASO) group requests for E0747, E0748 and E0749 require pre-authorization through Regence.
  • For all other commercial products:

    • Requests for E0747 require pre-authorization through Regence.
    • Requests for E0748 and E0749 are detailed in the "Physical Medicine" section and requests for authorization are submitted directly to eviCore healthcare (eviCore)

Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation) (PDF)

  • E0760, 20979

Definitive Lower Limb Prostheses (PDF)

  • Effective December 1, 2022: L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718. L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984. L5985, L5986, L5987

Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems (PDF)

  • E0784, E0787, S1034

Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)

  • L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191

Negative Pressure Wound Therapy in the Outpatient Setting (PDF)

  • 97605, 97606, 97607, 97608, E2402
    The policy requires an initial pre-authorization for a 1-month therapeutic trial and then after one month, another pre-authorization for continuation is required demonstrating improvement in the wound.

Noninvasive Ventilators in the Home Setting (PDF)

  • E0466

Power Wheelchairs: Group 3 (PDF)

  • K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and microprocessor-Controlled Knee- Ankle Foot Orthoses (PDF)

  • K1014, L5856, L5857, L5858

Sleep Medicine Program

  • Review the codes requiring authorization or notification in the Sleep medicine section on this list.

Genetic testing

Effective January 1, 2023: In In compliance with WA HB 1689, guideline-recommended biomarker testing in patients with recurrent, relapsed, refractory, or metastatic cancer (including stage 3 or 4) will not require prior authorization for Washington members. This does not include non-specific molecular pathology codes (81400-81408).

Genetic Testing for Alzheimer's Disease (PDF) - GT01

  • 81401, 81405, 81406

Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome (PDF) - GT02

  • 0235U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81351, 81352, 81404, 81405, 81406, 81432, 81433

Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease (PDF) - GT05

  • 81401

Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes (PDF) - GT06

  • 0238U, 81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406

Genetic Testing for Cutaneous Malignant Melanoma (PDF) - GT08

  • 81404

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (PDF) - GT10

  • 81225, 81227, 81401, 81402, 81404, 81405, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

Genetic Testing; Familial Hypercholesterolemia (PDF) - GT11

  • 81401, 81405, 81406, 81407

KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) - GT13

  • 81210, 81275,81276, 81311, 81403, 81404, 0111U

Preimplantation Genetic Testing of Embryos (PDF) - GT18

  • 89290, 89291, 81228, 81229, 81349

Genetic Testing; IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia (PDF) - GT19

  • 81120, 81121

Genetic and Molecular Diagnostic Testing (PDF) - GT20

  • 0232U, 0234U, 0235U, 0238U, 0244U, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81225, 81227, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81341, 81349, 81350, 81351, 81352, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81419, 81470, 81471, S3800, S3840, S3844, S3845, S3846, S3849, S3850, S3853, S3865, S3866

Biallelic RPE65 Variant-Associated Retinal Dystrophy (PDF) - GT21

  • 81406

Gene Expression Profiling for Melanoma (PDF) - GT29

  • 81552

BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy (PDF) - GT41

  • 81210

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF) - GT42

  • 81518, 81519, 81521, 81522, 81523, S3854

Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes (PDF) - GT43

  • 81243, 81244

Genetic Testing for CADASIL Syndrome (PDF) - GT51

  • 81406

Diagnostic Genetic Testing for α-Thalassemia (PDF) - GT52

  • 81257, 81258, 81259, 81269, 81404

Genetic Testing; Primary Mitochondrial Disorders (PDF) - GT54

  • 81401, 81403, 81404, 81405, 81440, 81460, 81465

Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) (PDF) - GT56

  • 0022U, 81210, 81235, 81275, 81276, 81404, 81405, 81406

Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies (PDF) - GT58

  • 0209U, 81228, 81229, 81349, 0156U, S3870

Myeloid Neoplasms and Leukemia (PDF) - GT59

  • 81120, 81121, 81351, 81352, 81401, 81402, 81403, 81450, 81455

PTEN Hamartoma Tumor Syndrome (PDF) - GT63

  • 0235U, 81321, 81322, 81323

Evaluating the Utility of Genetic Panels (PDF) - GT64

  • 81201, 81202, 81203, 81210, 81225, 81227, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81349, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81433, 81434, 81437, 81438, 81440, 81443, 81450, 81455, 81460, 81465, 81470, 81471

Genetic Testing for Methionine Metabolism Enzymes, including MTHFR (PDF) - GT65

  • 81401, 81403, 81404, 81405, 81406

Diagnosis of Inherited Peripheral Neuropathies (PDF) - GT66

  • 81403, 81404, 81405, 81406, 81324, 81325, 81326, 81448

Genetic Testing for Rett Syndrome (PDF) - GT68

  • 0234U, 81302, 81303, 81304, 81404, 81405, 81406

Duchenne and Becker Muscular Dystrophy (PDF) - GT69

  • 0218U, 81161, 81408

Fetal RHD Genotyping Using Maternal Plasma (PDF) - GT74

  • 81403

Genetic Testing for Macular Degeneration (PDF) - GT75

  • 81401, 81405, 81408

Whole Exome and Whole Genome Sequencing (PDF) - GT76

  • 0214U, 0215U, 81415, 81416

Genetic Testing for Heritable Disorders of Connective Tissue (PDF) - GT77

  • 81405, 81408

Genetic Testing; Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities (PDF) - GT78

  • 81228, 81229, 81349, 81405

Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79

  • 81228, 81229, 81349

Genetic Testing for Epilepsy (PDF) - GT80

  • 0232U, 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407, 81419

Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81

  • 81161, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853

Genetic Testing: Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies (PDF) - GT83

  • 0022U, 0037U, 0048U, 0211U, 0244U, 0250U, 0334U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81455

Genetic Testing for Neurofibromatosis Type 1 or 2 (PDF) - GT84

  • 81405, 81406, 81408

Physical Medicine

We partner with eviCore healthcare to administer our Physical Medicine program.

How to submit an authorization

  1. Review this entire page for similar services that require pre-authorization
  2. Verify member benefits, eligibility and pre-authorization requirements on the Availity Portal
  3. Determine whether a member's plan participates in this program by using the electronic authorization tool on the Availity Portal
  4. Obtain or verify an authorization with eviCore:

    1. Sign in to eviCore's portal
    2. Phone (855) 252-1115
    3. Fax (855) 774-1319
    4. View workarounds for eviCore system outages

Pain management

  • To determine which program an ASO member participates in, use the electronic authorization tool on the Availity Portal
  • We require authorization from eviCore for these codes: 00640, 22510, 22511, 22512, 22513, 22514, 22515, 27096, 61790, 61791, 62290, 62291, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63685, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 72285, 72295, G0259, G0260

Joint management

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine which program an ASO member participates in, use the electronic authorization tool on the Availity Portal.
  • We require authorization from eviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27130, 27132, 27134, 27137, 27138, 27332, 27333, 27334. 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27570, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916

Spine

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine which program an ASO member participates in, use the electronic authorization tool on the Availity Portal.
  • We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749, S2350, S2351

Physical therapy, speech therapy, occupational therapy (PT/ST/OT); chiropractic, acupuncture and massage
The initial evaluation and treatment visit does not require pre-authorization. If additional treatment is medically necessary, eviCore requires that a pre-authorization request be submitted within seven days of the initial visit.

Members on fully insured plans will no longer require pre-authorization for chiropractic, acupuncture and massage services. Some administrative service only (ASO) groups will still require pre-authorization for chiropractic, acupuncture and massage services.

  • To determine which program an ASO member participates in, use the electronic authorization tool on the Availity Portal
  • Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF).
  • We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 92630, 92633, 95851, 95852, 96105, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943, G0151, G0152, G0157, G0158, G0159, G0160, G0283, S8950, S9128, S9129, S9131, S9152

Washington Mandate

Pre-authorization is not required for an initial evaluation and management visit and up to six consecutive treatment visits (for a total of seven) in a new episode of care. After the patient’s sixth treatment visit an authorization is required.

We define a "new episode of care" as treatment for a new condition or diagnosis for which the patient has not been treated by a provider within the same Tax ID number and specialty within the previous 90 days and is not undergoing any active treatment for that condition or diagnosis. Anything beyond a new episode of care requires an authorization. When a member receives treatment for the same episode of care by different provider specialties, each provider specialty receives six treatment visits without requiring pre-authorization. View our FAQ (PDF) for more clarification on an episode of care.

The Physical Medicine program services include:

  • Acupuncture
  • Chiropractic
  • Massage therapy
  • Physical therapy
  • Occupational therapy
  • Speech therapy

This mandate applies to members on the following Washington plans:

  • Regence BlueShield (select counties in Washington) group and Individual members
  • Regence BlueCross BlueShield of Oregon group and Individual members on one of our Clark County, Washington products
  • Regence BlueShield of Idaho group and Individual members on one of our Asotin or Garfield County, Washington products

This mandate does not apply to the following members:

  • Medicare Advantage
  • Any individual or group plan not based in the state of Washington
  • BlueCross BlueShield Federal Employee Program® (BCBS FEP®)
  • Some Administrative Services Only plans*

*Some Administrative services only (ASO) groups may participate in this program. To determine whether your patient's plan participates in this program, use the electronic authorization tool on the Availity Portal.

Radiology

Contact Regence for pre-authorization for the following codes:

Computed Tomography to Detect Coronary Artery Calcification (PDF)

  • S8092

Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders (PDF)

  • 0651T, 91110, 91111, 91113

AIM Specialty Health

We partner with AIM to administer our radiology program which has two components: Radiology Quality Initiative (RQI) and Advanced Imaging Authorization. Please note, ASO groups who do not participate in the Advanced Imaging component still require an order number through the RQI component. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

  • Sign in to AIM's ProviderPortal
  • Phone 1 (877) 291-0509
  • View workarounds for AIM system outages
  • Contact AIM to obtain an order number for the following codes: 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 73221, 73222, 73223, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75574, 75635, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 0042T, 0501T, 0502T, 0503T, 0504T, 0648T, 0649T

Sleep medicine

We partner with AIM to administer our Sleep Medicine program. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

  • Login to AIM's ProviderPortal
  • Phone 1 (877) 291-0509
  • View workarounds for AIM system outages
  • Contact AIM to obtain an order number for the following codes: 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601, G0398, G0399, G0400

Cardiology

We partner with AIM to administer our Cardiology Program. Determine whether your patient's plan participates in this program by using the electronic authorization tool on Availity Essentials.

  • Login to AIM's ProviderPortal
  • Phone 1 (877) 291-0509
  • View workarounds for AIM system outages
  • Effective January 1, 2023: Contact AIM to obtain an order number for the following codes: 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 92920, 92924, 92928, 92933, 92937, 92943, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931

Specialty medications

CHG Healthcare Services and IEC Group members

Pre-authorization for certain specialty medications is required for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members. These members are part of our joint administration partnership with AmeriBen.

Pre-authorizations for CHG healthcare Services and IEC Group members should be submitted to VIVIO Health Help Desk at 1 (925) 365-6600. Note: This phone number should only be used for pre-authorizing specialty medications for these members.

The following medications require pre-authorization for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members:

HCPCS A9508, A9513, A9543, A9606, C9098, G2082, G2083, G9033, J0121, J0129, J0135, J0178, J0179, J0180, J0202, J0207, J0221, J0222, J0256, J0257, J0289, J0364, J0490, J0517, J0565, J0567, J0584, J0588, J0593, J0596, J0599, J0597, J0598, J0604, J0606, J0638, J0641, J0642, J0717, J0775, J0800, J0850, J0881, J0882, J0885, J0887, J0894, J0895, J0897, J1290, J1300, J1301, J1303, J3111, J1322, J1324, J1325, J1428, J1438, J1439, J1442, J1446, J1447, J1453, J1458, J1459, J1460, J1555, J1556, J1557, J1559, J1560, J1561, J1566, J1568, J1569, J1571, J1572, J1575, J1595, J1599, J1602, J1626, J1627, J1628, J1640, J1645, J1652, J1726, J1729, J1743, J1744, J1745, J1746, J1786, J1826, J1830, J1930, J1931, J1950, J1951, J1952, J2170, J2182, J2265, J2278, J2315, J2323, J2326, J2350, J2353, J2354, J2357, J2406, J2430, J2502, J2505, J2507, J2562, J2597, J2724, J2778, J2783, J2786, J2788, J2790, J2791, J2792, J2793, J2796, J2798, J2820, J2840, J2860, J2941, J3060, J3110, J3240, J3241, J3245, J3262, J3285, J3304, J3315, J3357, J3358, J3380, J3385, J3396, J3397, J3398, J3399, J3485, J3489, J7170, J7175, J7177, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7197, J7198, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7311, J7312, J7313, J7318, J7332, J7336, J7340, J7351, J7402, J7504, J7527, J7639, J7682, J7686, J7699, J8520, J8521, J8565, J8700, J8999, J9015, J9022, J9023, J9025, J9032, J9033, J9034, J9035, J9039, J9041, J9042, J9043, J9047, J9050, J9055, J9057, J9065, J9118, J9119, J9120, J9145, J9150, J9153, J9155, J9173, J9176, J9178, J9179, J9185, J9199, J9202, J9203, J9204, J9205, J9206, J9207, J9210, J9213, J9214, J9215, J9216, J9217, J9218, J9223, J9226, J9228, J9229, J9245, J9250, J9261, J9262, J9263, J9264, J9266, J9269, J9271, J9280, J9293, J9295, J9299, J9301, J9302, J9303, J9304, J9305, J9306, J9307, J9308, J9312, J9315, J9325, J9330, J9340, J9351, J9352, J9354, J9355, J9356, J9357, J9358, J9370, J9395, J9400, L8605, Q2041, Q2042, Q2043, Q2050, Q3028, Q4074, Q5101, Q5103, Q5104, Q5105, Q5106, Q5107, Q5108, Q5110, Q5111, Q5113, Q5114, Q5115, Q5116, Q5117, Q5119, Q5121, Q5122, Q9991, Q9992, S0088, S0182, S0189, S0190; CPT 90371, 90378.

Effective January 1, 2023, HCPCS Q5124 will be added to the specialty medication pre-authorization lists for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members.

Effective March 1, 2023, HCPCS J0219 and J9144 will be added to the specialty medication pre-authorization lists for CHG Healthcare Services (group #70000004) members.

Please review the complete list of specialty medications that require pre-authorization for these members:

Alsco Inc. members

Pre-authorization for certain specialty medications is required for Alsco Inc. (group #70000002) members. These members are part of our joint administration partnership with AmeriBen.

Pre-authorizations for Alsco members should be submitted to VIVIO Health Help Desk at 1 (925) 365-6600. Note: This phone number should only be used for pre-authorizing specialty medications for these members.

The following medications require pre-authorization for Alsco Inc. (group #70000002) members:

CPT 90371, 90378; HCPCS A9508, A9513, A9543, A9606, C9098, G2082, G2083, G9033, J0121, J0129, J0135, J0178, J0179, J0180, J0202, J0207, J0221, J0222, J0256, J0257, J0289, J0364, J0490, J0517, J0565, J0567, J0584, J0588, J0593, J0596, J0597, J0598, J0599, J0604, J0606, J0638, J0641, J0642, J0717, J0775, J0800, J0850, J0881, J0882, J0885, J0887, J0894, J0895, J0897, J1290, J1300, J1301, J1303, J1322, J1324, J1325, J1428, J1438, J1439, J1442, J1446, J1447, J1453, J1458, J1459, J1460, J1555, J1556, J1557, J1559, J1560, J1561, J1566, J1568, J1569, J1571, J1572, J1575, J1595, J1599, J1602, J1626, J1627, J1628, J1640, J1645, J1652, J1726, J1729, J1743, J1744, J1745, J1746, J1786, J1826, J1830, J1930, J1931, J1950, J1951, J1952, J2170, J2182, J2265, J2278, J2315, J2323, J2326, J2350, J2353, J2354, J2357, J2406, J2430, J2502, J2505, J2507, J2562, J2597, J2724, J2778, J2783, J2786, J2788, J2790, J2791, J2792, J2793, J2796, J2798, J2820, J2840, J2860, J2941, J3060, J3110, J3111, J3240, J3241, J3245, J3262, J3285, J3304, J3315, J3357, J3358, J3380, J3385, J3396, J3397, J3398, J3399, J3485, J3489, J7170, J7175, J7177, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7197, J7198, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7311, J7312, J7313, J7318, J7332, J7336, J7340, J7351, J7402, J7504, J7527, J7639, J7682, J7686, J7699, J8520, J8521, J8565, J8700, J8999, J9015, , J9022, J9023, J9025, J9032, J9033, J9034, J9035, J9039, J9041, J9042, J9043, J9047, J9050, J9055, J9057, J9065, J9118, J9119, J9120, J9145, J9150, J9153, J9155, J9173, J9176, J9178, J9179, J9185, J9199, J9202, J9203, J9204, J9205, J9206, J9207, J9210, J9213, J9214, J9215, J9216, J9217, J9218, J9223, J9226, J9228, J9229, J9245, J9250, J9261, J9262, J9263, J9264, J9266, J9269, J9271, J9280, J9293, J9295, J9299, J9301, J9302, J9303, J9304, J9305, J9306, J9307, J9308, J9312, J9315, J9325, J9330, J9340, J9351, J9352, J9354, J9355, J9356, J9357, J9358, J9370, J9395, J9400, L8605, Q2041, Q2042, Q2043, Q2050, Q3028, Q4074, Q5101, Q5103, Q5104, Q5105, Q5106, Q5107, Q5108, Q5110, Q5111, Q5113, Q5114, Q5115, Q5116, Q5117, Q5119, Q5121, Q5122, Q9991, Q9992, S0088, S0182, S0189, S0190.

Effective January 1, 2023, HCPCS Q5124 will be added to the specialty medication pre-authorization list for Alsco Inc. (group #70000002) members.

Effective March 1, 2023, HCPCS J0219 and J9144 will be added to the specialty medication pre-authorization list for Alsco Inc. (group #70000002) members.

View the list of specialty medications that will require pre-authorization for these members:

For all other members - view pharmacy pre-authorization requirements and submit pre-authorization requests.

Transplants and ventricular assist devices

Transplants -  Stem Cell

  • Reference our Medical Policy Manual for policies.
  • 38205, 38206, 38232, 38240, 38241, 38242, 38243, S2140, S2142, S2150

Transplants - Islet Transplantation (PDF)

  • 48160, 0584T, 0585T, 0586T, G0341, G0342, G0343

Transplants - Heart (PDF)

  • 33945

Transplants - Heart-Lung (PDF)

  • 33935

Transplants - Lung and Lobar Lung (PDF)

  • 32851, 32852, 32853, 32854, S2060

Transplants - Isolated Small Bowel Transplant (PDF)

  • 44135, 44136

Transplants - Small Bowel/Liver and Multivisceral Transplant (PDF)

  • 44135, 44136, 47135, 48554, S2053, S2054, S2152

Transplants - Liver Transplant (PDF)

  • 47135

Transplants - Pancreas Transplant (PDF)

  • 48554, S2065, S2152

Ventricular Assist Devices and Total Artificial Hearts (PDF)

  • 33927, 33928, 33929, 33975, 33976, 33977, 33978, 33979, L8698

Utilization management

Air Ambulance Transport (PDF)

  • A0435, A0430, S9960
  • Pre-authorization is required prior to elective fixed wing air ambulance transport.
  • Emergency air ambulance transports will be reviewed retrospectively for medical necessity; clinical documentation will be requested, if needed, upon receipt of the electronic claim.