Audience
Zip code - drawer
County - drawer

Sign in

Sign in

This pre-authorization list includes services and supplies that require pre-authorization or notification for FEP Blue Focus members in Utah. View pre-authorization requirements for FEP Blue Focus members of other Regence plans:

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.
  2. Members who fail to obtain prior approval will be assessed a $100 penalty.
  3. Before requesting pre-authorization, please verify eligibility and benefits via the Availity Portal as the member contract determines the covered benefits.
  4. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  5. 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.
  6. Precertification is required if the service or procedure requires an inpatient hospital admission. Elective medical inpatient services will be reviewed based on MCG Goal Length of Stay national/industry standards.
  7. Contract exclusions will not be pre-authorized. Denials may be appealed through FEP Provider Customer Service.
  8. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
  9. Urgent/Emergent services do not require pre-authorization but are subject to hospital admission notification requirements (see below).
  10. Pre-authorization decisions will be communicated.

Pre-authorization review timeframes

Type of review Timeframe Additional time allowed for review if additional information is needed:
Urgent 72 hours None
Standard initial and concurrent 15 calendar days None
Urgent concurrent 24 hours 72 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. 

How to submit a pre-authorization request or notification 

Expedited requests 

Use this process only when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy. 

  • Availity Portal: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request 
  • Via fax using the appropriate pre-authorization request form below 

Online

  • Submit an electronic pre-authorization request, and supporting clinical documentation through the Availity Portal Login>Patient Registration>Authorizations & Referrals>Authorizations o Learn more about submitting requests through Availity 
  • Submit a pre-authorization request form

Phone or fax 

Submit the appropriate pre-authorization request form only if unable to submit online or if submitting an expedited request:

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).

Hospice services

Prior approval is required for home hospice, continuous home hospice and inpatient hospice care services.
 

For listings of Preferred hospice providers, use the National Doctor & Hospital Finder

Maternity

Notification of pregnancy is requested.

Hospital admissions

Pre-authorization is required for elective inpatient admissions occurring on or after May 1, 2019. For more information, read our Frequently Asked Questions (PDF).

Chemical dependency and mental health

The following services require pre-authorization prior to patient admission. Emergency services do not require pre-authorization but are subject to admission notification requirements. 
  • Outpatient treatment
    • Partial hospitalization (Psychiatric or ASAM level 2.5 for Substance Use Disorders) and Intensive Outpatient: (Psychiatric or ASAM level 2.1 for Substance Use Disorders)
      • No pre-authorization is required unless provided by a free-standing residential facility.
    • PHP, IOP, group therapy, psychological testing, etc.
      • Requires pre-authorization for all services billed by a residential facility.
  • Inpatient mental health/inpatient detoxification
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Sub-Acute Detoxification / ASAM Level 3.7
    • Requires pre-authorization before the member is admitted for services. Case Management required.
  • Residential treatment: Psychiatric or ASAM Level 3.5 for Substance Use Disorders
    • Requires pre-certification and authorization before the member is admitted for services. Case Management required.

Radiology (CT scan/MRI/PET scan)

70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 70557, 70558, 70559, 71250, 71260, 71270, 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, 73221, 73222, 73223, 73225,  73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725,  74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635, 76376, 76377, 76380, 76390, 76391, 76497, 76498, 77011, 77012, 77013, 77014, 77021, 77022, 77046, 77047, 77048, 77049, 77078, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 0482T, 76390, 78071, 78072, 78205, 78206, 78320, 78451, 78452, 78469, 78494, 78607, 78647, 78710, 78803, 78807, 77084

0042T, 0332T, 0398T, 0501T, 0502T, 0503T, 0504T, 0558T, S8092, G0288, G0297

C8903, C8904, C8905, C8906, C8907, C8908

Genetic Testing (BRCA/LGR)

81162, 81212, 81215, 81216, 81217, 81163, 81164, 81165, 81166, 81167

Genetic Testing

0001M, 0001U, 0002M, 0002U, 0003M, 0003U, 0004M, 0005U, 0006M, 0007M, 0008U, 0009M, 0009U, 0010U, 0011M, 0012M, 0012U, 0013M, 0013U, 0014U, 0016U, 0017U, 0018U, 0019U, 0021U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0039U, 0040U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U,  0080U, 0081U, 0087U, 0088U, 0089U, 0090U, 0091U, 0092U, 0094U, 0101U, 0102U, 0103U, 0104U

81120, 81121, 81161, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81340, 81341, 81342, 81343, 81344, 81345, 81346, 81350, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471, 81479, 81490, 81493, 81500, 81503, 81504, 81506, 81507, 81508, 81509, 81510, 81511, 81512, 81518, 81519, 81520, 81521, 81525, 81528, 81535, 81536, 81538, 81539, 81540, 81541, 81545, 81551, 81595, 81596, 81599, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, G0452, G9143, S3722, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3849, S3850, S3852, S3853, S3854, S3861, S3865, S3866, S3870

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

Cardiac Rehabilitation

93797, 93798, S9472, G0422, G0423

Pulmonary Rehabilitation

S9473, G0424, G0237, G0238, G0239

Applied Behavior Analysis (ABA)

0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158

Cochlear Implants

69930, L8614, L8627, L8628, L8615, L8616, L8617, L8618, L8619

Prosthetic Devices

L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6386, L6388, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L7400, L7401, L7402, L7403, L7404, L7405, L7499, L7510, L7520, L7600, L7700, L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8035, L8039, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049

Specialty DME services

E0265, E0266, E0270, E0277, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0328, E0329, E0371, E0372, E0373, E0983, E0984, E0985, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1230, E1239, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, K0010, K0011, K0012, K0013, K0014, K0108, K0733, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899

Surgical Services

Surgery for Morbid Obesity

  • 43644, 43645, 43770, 43773, 43775, 43845, 43846, 43847, 43848
  • Pre-authorization is required even if FEP is secondary to other insurance.

Oral Maxillofacial Surgeries

0510T, 0511T, 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

Surgery to correct congenital anomalies

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

Surgical Procedures for Breast Reduction / Augmentation

  • Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
  • 15777, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342

Other surgical services

0524T, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 19396, 20650, 20662, 20663, 20665, 20670, 20680, 20690, 20692, 20693, 20694, 20696, 20697, 20900, 20902, 20920, 20922, 20924, 20926, 20930, 20931, 20936, 20937, 20938, 20939, 20955, 20956, 20962, 20970, 20985, 21026, 21030, 21031, 21032, 21034, 21040, 21044, 21045, 21046, 21047, 21048, 21049, 21116, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21188, 21208, 21209, 21230, 21235, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, 21740, 21742, 21743, 22010, 22015, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22857, 22858, 22859, 22861, 22862, 22864, 22865, 22867, 22868, 22869, 22870, 23020, 23035, 23040, 23044, 23100, 23101, 23105, 23106, 23107, 23120, 23125, 23130, 23170, 23172, 23174, 23180, 23182, 23184, 23190, 23195, 23395, 23397, 23405, 23406, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23470, 23472, 23473, 23474, 23480, 23485, 23490, 23491, 23700, 23800, 23802, 23900, 23920, 23921, 24134, 24140, 24344, 24346, 24498, 26500, 26502, 26541, 26542, 26545, 26992, 27000, 27001, 27003, 27005, 27006, 27025, 27027, 27030, 27033, 27036, 27050, 27052, 27054, 27057, 27070, 27071, 27080, 27097, 27098, 27100, 27105, 27110, 27111, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27140, 27146, 27147, 27151, 27156, 27161, 27165, 27170, 27175, 27176, 27177, 27178, 27179, 27181, 27185, 27187, 27275, 27279, 27280, 27282, 27284, 27286, 27290, 27295, 27303, 27305, 27306, 27307, 27325, 27326, 27330, 27331, 27332, 27333, 27334, 27335, 27350, 27360, 27380, 27381, 27385, 27386, 27390, 27391, 27392, 27393, 27394, 27395, 27396, 27397, 27400, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27430, 27435, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27448, 27450, 27454, 27455, 27457, 27465, 27466, 27468, 27470, 27472, 27475, 27477, 27479, 27485, 27486, 27487, 27495, 27496, 27497, 27498, 27499, 27570, 27580, 27598, 27600, 27601, 27602, 27605, 27606, 27607, 27612, 27620, 27625, 27626, 27640, 27641, 27650, 27652, 27654, 27656, 27658, 27659, 27664, 27665, 27675, 27676, 27680, 27681, 27685, 27686, 27687, 27690, 27691, 27692, 27695, 27696, 27698, 27700, 27702, 27703, 27705, 27707, 27709, 27712, 27715, 27720, 27722, 27724, 27725, 27726, 27730, 27732, 27734, 27740, 27742, 27745, 27860, 27870, 27871, 27889, 27892, 27893, 27894, 27899, 28005, 28238, 29800, 29806, 29807, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29862, 29863, 29866, 29867, 29868, 29871, 29873, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29895, 29897, 29898, 29899, 29914, 29915, 29916, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30520, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 40490, 40500, 40806, 40808, 40810, 40812, 40814, 40816, 40819, 40820, 41010, 41100, 41105, 41108, 41110, 41112, 41113, 41114, 41115, 41116, 41120, 41130, 41150, 41520, 42000, 42100, 42104, 42106, 42107, 42120, 42140, 42145, 42160, 42300, 42305, 42310, 42320, 42330, 42335, 42340, 67971, 67973, 67974, 67975, 69310, 69641, 69642, 69643, 69644, 69646

Gender reassignment surgery

  • A treatment plan, including all surgeries planned and the estimated date each will be performed, is required.
  • Pre-authorization is required even if FEP is secondary to other insurance.
  • 17380, 19303, 19304, 53410, 54125, 54520, 53430, 54400, 54401, 54405, 54660, 54690, 55175, 55180, 55899, 55970, 55980, 56805, 56625, 57110, 57291, 58292, 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

Gene Therapy

Q2041, Q2042, J3398, S2107, 0537T, 0538T, 0539T, 0540T

Transplants

Artificial Heart

33927, 33928, 33929

Blood or Marrow Stem Cell Transplants

38240, 38241, S2142, S2150

Organ/Tissue Transplants

32851, 32852, 32853, 32854, 33935, 33945, 44135, 44136, 47135, 47136, 48160, 48554, G0341, G0342, G0343, S2053, S2054, S2060, S2152

Transplant Travel

S9992, S9994

Air Ambulance Transport (Non-Emergent)

  • A0430, A0431, A0435, A0436

Prescription drugs

Certain prescription drugs require pre-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.