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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

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Precertification Requirements and Forms

PW_A085072
 
Standard Precertification Requirements  
Sleep Management Precertification CPT Codes
Radiation Therapy Precertification CPT Codes
Precertification Requirements List All LOB - effective 3/01/2013
Medicare Advantage Precertification Requirements List
Precertification Procedure Codes Sheet – effective 3/1/2013
Outpatient Diagnostic Imaging Precertification Procedure Codes Sheet - effective 01/01/2012
 
Precertification Forms  
Continuation of Care Coverage Request Form
Medicare Advantage General Precert Form
MPI – Stress Echo Clinical Worksheet
Precertification Form for Procedures and Diagnostics
Pre-Existing condition review for Radiology and Pre-Service Reviews
Primary Care Physicians Referral Form
Request for Transition of Out of Network Care (TOC) – HMO/POS members
Request for Transition of Out of Network Care (TOC) – PPO/ASO Group members
 
Medical-Surgical Clinical Data Submissions Tools  
Medical-Surgical Clinical Data Submissions Tools
 
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