2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 3. How You Get Care
Page 24
Section 3. How You Get Care
Page 24
• Special prior authorization situations related to coordination of benefits (COB)
The examples below provides the special situations regarding prior approval and precertification when Medicare is the primary payor.
Service Type: Inpatient hospital admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Not applicable
Service Type: Medicare hospital benefits exhausted and you do not want to use your Medicare lifetime reserve days
Primary Payor: Medicare Part A benefits not provided
Precertification: Yes
Prior Approval: Not applicable
Service Type: Gender affirming surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Yes
Service Type: Gender affirming surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Severe obesity surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Yes
Service Type: Severe obesity surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Residential treatment center admission – inpatient
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Not applicable
Service Type: Residential treatment center – outpatient care
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
The examples below provides the special situations regarding prior approval and precertification when Medicare is the primary payor.
Service Type: Inpatient hospital admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Not applicable
Service Type: Medicare hospital benefits exhausted and you do not want to use your Medicare lifetime reserve days
Primary Payor: Medicare Part A benefits not provided
Precertification: Yes
Prior Approval: Not applicable
Service Type: Gender affirming surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Yes
Service Type: Gender affirming surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Severe obesity surgery when performed during an inpatient admission
Primary Payor: Medicare Part A
Precertification: No
Prior Approval: Yes
Service Type: Severe obesity surgery in an outpatient hospital or ambulatory surgical center (ASC)
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
Service Type: Residential treatment center admission – inpatient
Primary Payor: Medicare Part A
Precertification: Yes
Prior Approval: Not applicable
Service Type: Residential treatment center – outpatient care
Primary Payor: Medicare Part B
Precertification: Not applicable
Prior Approval: Yes
The examples below provides the special situations regarding prior approval and precertification when another healthcare insurance is the primary payor.
Service Type: Inpatient hospital admission
Primary Payor: Other healthcare insurance
Precertification: No
Prior Approval: Not applicable
Service Type: Gender affirming surgery when performed during an inpatient admission
Primary Payor: Other healthcare insurance
Precertification: Yes
Prior Approval: Yes