Prior authorization - Medical services and treatments requiring pre-approval

Sep 17, 2026

Prior authorization guidance outlines when certain medical services and treatments require pre-approval or precertification before receiving care. The review ensures medical necessity and states that failing to obtain approval may lead to denial or reduced benefits. It explains that providers or facilities usually handle requests, but members remain responsible for confirming submission and providing required evidence. It also lists specific high-cost services subject to approval, plus exceptions, and describes FEP Blue Focus penalties and special Medicare-related rules.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Prior authorization overview

Basic Option and Standard Option requirements

Services requiring prior approval

Exceptions

FEP Blue Focus rules

Penalty for missing prior approval

Services requiring prior approval under FEP Blue Focus

Exceptions and Medicare/special payer notes

Prior authorization Certain medical services and treatments need prior authorization before you receive care. Depending on the type of care you require, you may need pre-approval (in the form of a prior authorization, precertification or both) . We review the service or treatment to ensure it is medically necessary. If you do not obtain pre-approval, there may be a reduction or denial of your benefit. In most cases, your doctor or facility will take care of approval requests. Because you are still responsible for ensuring that your care is approved, you should always ask your provider if they have contacted us and provided all the necessary information. You can call the number on the back of your member ID card to see if we have received the request. Basic Option and Standard Option You must obtain prior approval for these services under both Basic Option and Standard Option in all outpatient and inpatient settings unless otherwise noted. Precertification is also required if the service or procedure requires an inpatient hospital admission. Contact us using the customer service phone number listed on the back of your member ID card before receiving these types of services and we will request the medical evidence needed to make a coverage determination: • Gene therapy and cellular immunotherapy, for example, CAR-T and T-Cell receptor therapy • High-cost drugs • Air Ambulance Transport (non-emergent) • Outpatient facility-based sleep studies • Applied behavior analysis (ABA) • Gender affirming surgery • Genetic testing • Hearing aids • Surgical services • Proton beam therapy • Stereotactic radiosurgery • Stereotactic body radiation therapy • Reproductive Services • Sperm/egg storage • Hospice care • Organ/tissue transplants • Clinical trials for certain blood or marrow stem cell transplants • Transplant travel • Prescription drugs and supplies – Certain prescription drugs and supplies require prior approval • Medical foods covered under the pharmacy benefit require prior approval • Residential treatment center care Exceptions You do not need precertification in these cases: • You are admitted to a hospital outside the United States; with the exception of admissions for gender affirming surgery and admissions to residential treatment centers, and skilled nursing facilities. • You have another group health insurance policy that is the primary payor for the hospital stay; with the exception of admissions for gender affirming surgery. • Medicare Part A is the primary payor for the hospital or skilled nursing facility stay; with the exception of admissions for gender affirming surgery. FEP Blue Focus You must obtain prior approval for these services in all outpatient and inpatient settings unless otherwise noted. Failure to obtain prior approval will result in a $100 penalty. Precertification is also required if the service or procedure requires an inpatient hospital admission. However, special rules apply when Medicare or another payer is primary, as explained later in this section. If an inpatient admission is necessary, precertification is also required. Contact us using the customer service phone number listed on the back of your member ID card before receiving these types of services and we will request the medical evidence needed to make a coverage determination: • Gene Therapy and Cellular Immunotherapy, including Car-T and T-cell receptor therapy • High-cost drugs • Air Ambulance Transport (non-emergent) • Applied behavior analysis (ABA) • Genetic testing • Surgical services • Proton beam therapy • Stereotactic radiosurgery • Stereotactic body radiation therapy • Reproductive services • Sperm/egg storage • Hospice care • Cardiac rehabilitation • Cochlear implants • Residential treatment center care • Prosthetic devices (external) • Pulmonary rehabilitation • Radiology, high technology • Specialty durable medical equipment (DM

FAQs

What is prior authorization, and why is it needed?

Prior authorization is a pre-approval or precertification process that ensures a requested service or treatment is medically necessary before care is received.

What happens if pre-approval is not obtained?

In many cases, benefits may be reduced or denied. Under FEP Blue Focus, failure to obtain prior approval results in a $100 penalty.

When is precertification not required?

Precertification is not needed for certain situations such as hospital admissions outside the United States, when another group health insurance policy is the primary payor, or when Medicare Part A is primary, with stated exceptions.

Sep 17, 2026

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