Bcbs Federal Copay

The Federal Employee Program (FEP) is a nationwide Federal Employees Health Benefits program administered through local Blue Cross and Blue Shield Association plans. This program should not be confused with HMSA's Federal Employees Health Benefits (FEHB) program (coverage code 87). The FEP membership cards are identified by coverage codes 104, 105, and 106 for the Standard Option and 111, 112, and 113 for the Basic Option. FEP Blue Focus enrollment codes are 131, 132 and 133.

Basic Option members must use preferred providers for all medical care (with some exceptions, such as emergency care). There's a copayment for most services and no deductible.

You mentioned out-of-pocket maximum, what does that mean? In the examples we used, we mentioned the term out-of-pocket maximum. An out-of-pocket maximum is the annual limit on the amount of money that you would have to pay for health care services, not including monthly premiums. We have the BCBS Federal Basic plan now. I'm trying to figure out if our baby has to go to the NICU for several weeks (most likely scenario), do we just pay the hospital copay or are there lots of additional charges where it would make sense to switch to the BCBS Federal standard plan with a deductible? Copays, deductibles and coinsurance are common examples of cost share. What Are Copays? A copay, or copayment, is a set amount that you pay at the time and place of service. Not all plans and services require copays. The amount of your copay may vary based on factors such as where you receive care. The Blue Cross and Blue Shield Service Benefit Plan is the number one health insurance choice for federal employees, retirees and their families. A copay is a set.

Providers should always verify member eligibility via HHIN under Blue Exchange or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

Information on member benefits and claims status is also available on HHIN or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

Pre-certification

FEP requires precertification prior to your inpatient admission. Precertification may be required for members despite having another insurance carrier primary to FEP.

When FEP is the secondary insurance carrier and the patient's primary insurance limits are met, FEP becomes their primary insurance carrier.

If you have an emergency inpatient admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily functions, you, your representative, the physician or the hospital must call us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

We will reduce our benefits for the inpatient hospital stay by $500 even if you have obtained prior approval for the services or procedure being performed during the stay, if no one contacts us for precertification.

Medical Admissions

To get precertification before an inpatient hospital admission, please call the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

Behavioral Health Admissions

Prior approval is no longer required for outpatient professional or outpatient facility care for mental health and substance abuse treatment.

Inpatient mental health or alcohol and substance abuse services require precertification. A provider with the appropriate clinical background (e.g., M.D., Ph.D., Psy.D., C.S.W., C.S.A.C. or R.N.) and who is knowledgeable about the patient's clinical condition should call or fax HMSA's Behavioral Health Services - Commercial, FEP, Fed 87 (Beacon Health Options) to open a case file for the patient, arrange an initial evaluation, and precertify any services. Be sure to have the following information available:

The patient's name and FEP member ID number.
The name of the facility/program to which the member will be admitted.
The name and provider number of the admitting psychiatrist or psychologist.
The date of the proposed admission.
Clinical information about the patient, including the diagnosis and proposed treatment regimen.

We'll give a verbal precertification at the time of the initial phone call for an admission requested by a specially contracted provider. FEP/HMSA will send a follow-up letter within seven working days with the following information:

Federal Employees Blue Cross Blue Shield 2021

A precertification number.
The number of inpatient days approved.
The effective date of the precertification.
Please note that a precertification from FEP/HMSA confirms that the services are necessary and appropriate but doesn't guarantee the availability of benefits.

To precertify ongoing services, a provider with the appropriate clinical background (e.g., M.D., Ph.D., Psy.D., C.S.W., C.S.A.C. or R.N.) should make subsequent calls to HMSA with clinical data to discuss the patient's status.

Bcbs Federal Copay For Mri

Prior Approval

The following services require prior approval for members with Basic Option plan:

Bcbs Federal Copay For Physical Therapy

Gene therapy and cellular immunotherapy, for example CAR-T and T-Cell receptor therapy;
Air ambulance Transport (non-emergent);
Outpatient sleep studies performed outside the home;
Applied behavior analysis(ABA);
BRCA testing and testing for large genomic rearrangements in the BRCA1 and BRCA2 genes- you must receive genetic counseling and evaluation services before preventive BRCA testing is performed.

Bcbs Federal Copay 2019

Surgical services - The surgical services on the following list require prior approval for care performed by Preferred, Participating/Member, and Non-participating/Non-member professional and facility providers:

- Outpatient surgery for morbid obesity;
- Outpatient surgical correction of congenital anomalies;
- Outpatient surgery needed to correct accidental injuries to jaw, cheeks, lips, tongue, and the roof and floor of the mouth;
- Gender reassignment surgery.

Outpatient Intensity Modulated Radiation Therapy (IMRT)- Prior approval is required for all outpatient IMRT services except IMRT related to the treatment of the head, neck, breast, prostate or anal cancer. Brain cancer is not considered a form of head or neck cancer therefore, prior approval is required for IMRT treatment of brain cancer.

Hospice care - Prior approval is required for home hospice, continuous home hospice or inpatient hospice care services. We will advise you which home hospice care agencies we have approved.
Organ/tissue transplants - Prior approval is required for both the procedure and the facility.
- Organ transplant procedure
- Blood or marrow stem cell transplants must be performed in a facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT) or in a facility designated as a Blue Distinction Center for Transplants or as a Cancer Research Facility.
Clinical trials for certain blood or marrow stem cell transplants
Prescription drugs and supplies- Contact CVS Caremark, our Pharmacy Program administrator to request prior approval or to obtain a list of drugs and supplies that require prior approval.
Medical Foods covered under the pharmacy benefit require prior approval.

Bcbs Therapy Copay

To get preauthorization for the services listed above, call the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

To get preauthorization for select prescription drugs, call the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii's Retail Pharmacy.

Morbid Obesity

Bcbs Federal Standard Copay

Preauthorization is required for outpatient surgery for morbid obesity.

Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements

Diagnosis of morbid obesity for a period of two years prior to surgery.
Participation in a medically supervised weight loss program, including nutritional counseling, for at least three months prior to the date of surgery. (Note: Benefits aren't available for commercial weight loss programs.
Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise.
Evidence that attempts at weight loss one year before surgery have been ineffective.
Psychological assessment of the member's ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse.
Patient hasn't smoked in the six months before surgery.
Patient hasn't been treated for substance abuse for one year before surgery.

Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements:

All criteria listed above for the initial procedure must be met again.
Previous surgery for morbid obesity was at least two years before the repeat procedure.
Weight loss from the initial procedure was less than 50 percent of the member's excess body weight at the time of the initial procedure.
Member complied with previously prescribed postoperative nutrition and exercise program.

Claims for the surgical treatment of morbid obesity must include documentation from the patient's provider(s) that all pre-surgical requirements have been met.

Dental, Vision and Physical Therapy Benefits

Dental benefits on Basic Option plans cover preventive dental care services only. Predetermination/preauthorization is not required for dental benefits. Information on covered dental benefits is available at www.fepblue.org or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

Vision benefits for Basic Option plans includes eye examinations related to a specific medical condition and one pair of eyeglasses, replacement lenses, or contact lenses per incident to correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery. Information on eligibility and benefits is available on HHIN or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

Physical, Occupational, and Speech Therapy Benefits

Physical therapy benefits for FEP Blue Focus plans include outpatient physical, occupational, and speech therapy limited to 50 visits total for all three services per person per year. FEP doesn't require authorization through Landmark. Benefit information is available on www.fepblue.org or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii

Claims Filing Information

For services in Hawaii, please submit claims on a CMS-1500 or UB-04 form, as appropriate, to the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

Information on eligibility, benefits, and claims status is available on HHIN or by calling the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii.

Provider Fee schedules are available on HHIN.

How to Submit a Provider Reconsideration

Please mail your request for reconsideration in writing, along with any additional information, to the Federal Employee Program (FEP) of Blue Cross Blue Shield of Hawaii, Attn: Reconsiderations.

FEP will notify you of its decision no later than 30 days after receiving all documentation reasonably needed to render a decision.

If FEP decides in your favor, payment will be made. If the determination isn't in your favor, the letter will explain your rights to an appeal.