September 16, 2021
For dates of service January 1, 2022, and after, pre-certification will be required for inpatient stays for all Blue Cross and Blue Shield Federal Employee Program (FEP) members.
FEP inpatient stays will go through a process to evaluate:
- medical necessity
- procedure (if one is to be performed)
- number of days required to treat the condition
- any applicable benefit criteria
If an inpatient stay is not pre-certified but determined to be medically necessary, payments for the inpatient hospital stay will be reduced by $500 and will be assigned to provider. If the stay is not pre-certified and determined not medically necessary,
FEP will not provide benefits for inpatient room and board or inpatient physician care.
This change will fulfill the contract requirements in the members’ Blue Cross
and Blue Shield Service Benefit Plan brochure (Standard and Basic Option: RI 71-005; FEP Blue Focus: RI 71-017). More information about FEP pre-certification and the process will be in an upcoming Provider News.