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20 11/2005
PRE-CERTIFICATION REQUIREMENTS
FOR
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC.
PARTICIPATING PROVIDER (INDEMNITY) AND PREFERRED PROVIDER ORGANIZATION (PPO)
AND
BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
BLUECHOICE HEALTHCARE PLAN (HMO), BLUECHOICE OPTION (POS), BLUE DIRECT (HMO/POS)
EFFECTIVE DATE: November 1, 2005
Eligibility/benefits can be verified by accessing the BCBSGa web site www.bcbsga.com or
by calling customer care 1-800-241-7475 (Mon – Fri, 7 am – 7 pm ET)
Eligibility and Benefits – Service pre-certification is based on member’s benefit plan/eligibility at the time the service is
reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is
responsible for verification of member eligibility/covered benefits. Except when an emergency, failure to obtain pre-
certification prior to rendering the designated services listed below will result in denial of reimbursement.
All Imaging Procedures for All Lines of Business (except in an emergency or for inpatient admissions)
The following procedures must be pre-certified through National Imaging Associates (NIA) 1-866-642-9704 (Mon – Fri, 8 am –
8 pm ET) once eligibility and benefits have been verified with BCBSGa/BCSHP
• CT Scans (Except guidance related, codes 72126,
72129 and 72132)
• MRIs
• Nuclear Cardiology
• PET Scans
• CTAs and MRAs
HMO, POS and Blue Direct HMO
Institutional Admissions Requiring Pre-certification
• Acute Inpatient (Including Transplants)
• Sub-acute Inpatient (Skilled Nursing and Long
Term Care)
• Inpatient Rehabilitation
• All out-of-network/out-of-area non-emergency
services
• All mental health and substance abuse services –
Call 1-800-292-2879
Outpatient Services Requiring Pre-certification
• Arthroscopy – shoulder/knee
• Biofeedback
• EMG/Nerve Conduction Studies
• Epidural/Facet Injections for Pain Management
• Gastric Obesity Surgery
• Home Health Skilled Nursing
• Hysterectomy (Age < 35)
• Orthognathic/TMJ
• Reconstructive Surgery
• Sleep Studies
• UPPP
• Transplant Evaluations – Call 1-866-694-0724 or
Fax 1-888-896-8679
• All mental health and substance abuse services –
Call 1-800-292-2879
Service Coverage
POS – Services listed above require pre-certification and will be denied if rendered without the appropriate pre-certification
regardless of whether rendered in or out-of-network. Except for Blue Direct specialists performing services that no longer
require pre-certification must have a referral for in-network benefit payment. If there is no referral or the member self-
referred, the out-of-network benefit level will be paid.
HMO – Services listed above require pre-certification and will be denied if rendered without the appropriate pre-certification
regardless of whether rendered in or out-of-network. HMO members do not have benefits for non-emergency services
rendered outside of the network without obtaining an authorization.
Indemnity (PAR) and Preferred Provider Organization (PPO)
Institutional Admissions Requiring Pre-certification
• Acute Inpatient (Including Transplants)
• Sub-acute Inpatient (Skilled Nursing and Long
Term Care)
• Inpatient Rehabilitation
• All mental health and substance abuse services – Call 1-
800-292-2879
All facilities must notify us within 24 hours or the next business day after admission.