Please Note: Producers will receive this notice in two business days.

Precertification changes effective September 1, 2011

We are implementing important changes to the list of services and drugs that require precertification. These changes take effect September 1, 2011, and will help us to achieve consistency across product lines as we continue to look for ways to simplify the precertification process.

Highlights

The new precertification requirements will apply to all commercial products for dates of service on or after September 1, 2011. The following precertification requirements will be added for all commercial products:

• cataract surgery;
• cochlear implant surgery;
• hyperbaric oxygen treatments;
• medical infusion/injectable drug additions;
• pain management procedures (paravertebral facet joint injections, transforaminal epidural injections, epidural injections);
• potentially cosmetic procedures;
• uvulopalatopharyngoplasty (throat surgery).

The following precertification requirements will be removed for all commercial products:

• sleep studies;
• cardiac rehabilitation*;
• pulmonary rehabilitation*.

*Please note that speech therapy still requires precertification.

Precertification process

Participating physicians will obtain precertification for services they provide members or those provided by a participating facility. When services are provided by a BlueCard^® provider of another Blue plan or, if an out-of-network provider is used, the member is responsible for obtaining precertification.

If a service requires precertification, it does not mean that the member is eligible to receive that service or guaranteed payment for that service. Coverage and payment are dependent upon, among other things, the member being actively enrolled in the health benefits plan when the precertification is issued and when approved services occur.

Communication to customers

We will send a letter to all commercial groups next week. All members will be notified through Update magazine in August.

Group letter

After July 1, you will be able to view both the old and new precertification lists on ibx.com. The old lists will be removed from ibx.com on September 1.

We encourage you to talk to your customers about the changes we are making to our precertification lists.

If you have any questions, please contact your IBC account executive.

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