FEP Basic and Standard Plan pre-authorization List

FEP Basic Plan and Standard Plan Pre-authorization List

This pre-authorization list includes services and supplies that require pre-authorization or notification for FEP Basic Plan and Standard Plan members.

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 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. Contract exclusions will not be pre-authorized. Denials may be appealed through FEP Provider Customer Service.
  6. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
  7. Urgent/Emergent services do not require pre-authorization but are subject to hospital admission notification requirements (see below).
  8. Pre-authorization decisions will be communicated.
Pre-authorization review timeframes
Type of reviewTimeframeAdditional time allowed for review if additional information is needed:
Urgent72 hoursNone
Standard initial and concurrent15 calendar daysNone
Urgent concurrent24 hours72 hours
Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.

Use PreManage for notification

We receive admissions and discharge information through PreManage.

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 the Availity Portal 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 pre-authorization request.

This applies to pre-authorizations for our group and Individual, Uniform Medical Plan (UMP) and Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members. It does not currently include Medicare Advantage pre-authorizations. View the services that may receive automated approval (PDF).

Applied Behavior Analysis (ABA)

  • Pre-authorization is required prior to the initial treatment.
  • Pre-authorization is required for continued ABA and related services, including assessments, evaluations and treatment.
  • 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158

BRCA testing

  • Pre-authorization is required for BRCA testing and testing for large genomic rearrangements in the BRCA1 and BRCA2 genes whether performed for preventive or diagnostic reasons.
  • 81212, 81215, 81216, 81217, 81162, 81163, 81164, 81165, 81166, 81167

Clinical trials for certain organ/tissue transplants - for blood or marrow stem cell transplants

  • S9988, S9990, S9991

Congenital abnormalities (Surgical correction)

  • 0254T, 23400, 27158, 27258, 27259, 27727, 31300, 33813, 33814, 34707, 34708, 35180, 35182, 35184, 40700, 40701, 40702, 40720, 40761, 42200, 42205, 42210, 42215, 42220, 42225, 43313, 43314, 44126, 44127, 44128, 47700, 50070, 50135, 50405, 52400, 61613. 61680, 61682, 61684, 61686, 61690, 61692, 61705, 61708, 61710, 63250, 63251, 63252, 69320. 93580, 93581

Gender reassignment surgery

  • A treatment plan, including all surgeries planned and the estimated date each will be performed, is required.
  • 17380, 19303, 19304, 53410, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 55899, 55970, 55980, 56625, 56805, 57110, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720, 58999, C1813, C2622,

Intensity-modulated radiation therapy (IMRT)

  • Prior approval is required for all outpatient IMRT services EXCEPT those related to treatment of the head, neck, breast, prostate or anal cancer. NOTE: Brain cancer is not considered a form of head or neck cancer; therefore, prior approval is required for IMRT treatment of brain cancer.
  • 77301, 77338, 77385, 77386
  • G6015, G6016

Obesity surgery (bariatric)

  • 43644, 43645, 43770, 43773, 43775, 43845, 43846, 43847, 43848

Oral/Maxillofacial surgery

  • Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth.
  • 0150T, 1511T, 21010, 21050, 21060, 21070, 21073, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21440, 21445, 21452, 21454, 21461, 21462, 21465, 21470, 21480, 21485, 21490, 21497, 29804, 40510, 40520, 40525, 40527, 40530, 40650, 40652, 40654, 40800, 40801, 40804, 40805, 40830, 40831, 41000, 41005, 41006, 41007, 41008, 41009, 41015, 41016, 41017, 41018, 41250, 41251, 41252, 42180, 42182

Air ambulance transport (non-emergent)

  • A0430, A0431, A0435, A0436

Sleep studies

  • Pre-authorization is required for sleep studies performed outside a home setting: 95782, 95783, 95803, 95805, 95807, 95808, 95810, 95811

Prescription drugs

Certain prescription drugs require prior authorization. Contact CVS Caremark at 1 (800) 624-5060 to request prior approval or to obtain a list of the drugs that require prior approval.