Blue Plans obtaining pre-authorization information for Regence members: Members of some group health plans may have terms of coverage or benefits that differ from the information presented here. The following information describes the general Regence policies and is provided for reference only. This information is NOT to be relied upon as pre-authorization or pre-certification for health care services and is NOT a guarantee of payment. To verify coverage or benefits or determine pre-certification or pre-authorization requirements for a particular member, call 1-800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.

This list does not pertain to Group or Individual products, Medicare products or Federal Employee Program (FEP) members. Please contact your provider relations representative for copies of previous lists.

Upcoming List

• Effective May 1, 2012 indicated in green text

Uniform Medical Plan – Pre-Authorization
Phone: 1 (888) 849-3682, Fax: 1 (877) 663-7526

UMP will follow Regence policy for many services, as long as Regence policy does not conflict with Washington State Health Technology Assessments (HTA) (PDF). For the Uniform Medical Plan, HTA decisions supersede Regence medical policy.

Important pre-authorization reminders

1. Before requesting pre-authorization, please verify eligibility and benefits via the Provider Center.
2. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
3. Verification of member eligibility is valid if obtained within five business days of service except in the case of misrepresentation.
4. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
5. Medical policies related to specific pre-authorization requirements are available.
6. Potentially investigational services may also be considered medically necessary for select diagnoses. Please refer to the Regence Clinical Edits by Code list for additional information. Unlisted codes may be used for potentially investigational services and are subject to review. 
7. Urgent/Emergent services do not require pre-authorization.
8. Pharmacy prior authorization information and forms can be foundat the RegenceRx Physician Web site.
9. Please note that a pre-authorization does not guarantee payment for requested services. Regence reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits.
10. Pre-authorization approval will be communicated by phone and a pre-authorization approval number will be provided.
11. Pre-authorization denials will be communicated both in writing and by phone.

Pre-authorization for investigational services and supplies is not required as such charges are typically contract exclusions and ineligible for payment. Charges for investigational services and supplies are denied with financial responsibility assigned to the member.
Potentially investigational services are services that are considered investigational, but for select diagnoses, may also be considered medically necessary, please refer to the Regence Clinical Edits by Code list for additional information. Unlisted codes may be used for potentially investigational services and are subject to review. 

• View investigational and potentially investigational procedures on the current Regence Clinical Edits by Code list
• View a sample non-covered services member consent form (PDF).

Regence uses Milliman Care Guideline as the basis for determining medical necessity for Mental Health and Substance Abuse services. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of guidelines for specific services. 

• Detox/Inpatient/Partial admissions: Notification upon admission required. Concurrent review will occur after 2 business days.
• Chemical dependency intensive outpatient: Notification upon admission required. Concurrent review will occur after 8 weeks.
• Outpatient mental health, outpatient chemical dependency, and intensive outpatient mental health: Concurrent review will occur after 20 visits.
• Residential Treatment Center (RTC): Pre-authorization is required prior to patient admission.

All hospital admissions require notification

Concurrent review will occur after 7 days.

Long Term Acute Care Facility (LTAC)

Pre-authorization is required prior to member admission

Rehabilitation

Pre-authorization is required prior to member admission

Skilled Nursing Facility (SNF)

Pre-authorization is required prior to member admission

Potentially cosmetic procedures -
procedures to restore or improve appearance that may also correct a functional impairment.

Pre-authorization not required for initial breast reconstruction one or two stages and nipple/areola reconstruction following mastectomy.

UMP will follow Regence practice for potentially cosmetic procedures as long as that practice does not conflict with HTA Decisions, which supersede Regence Medical Policy.

Please refer to the Regence Clinical Edits by Code list for cosmetic and potentially cosmetic procedures.

Potentially investigational services are services that are considered investigational, but for select diagnoses, may also be considered medically necessary.

May not be covered under the member's contract. UMP will follow Regence practice for potentially investigational services as long as that practice does not conflict with HTA Decisions, which supersede Regence Medical Policy.

Pre-authorization is recommended for any policy that has specific medical necessity criteria in addition to the experimental and investigational language.

Unlisted codes may be used for potentially investigational services and are subject to review.
Please refer to the Regence Clinical Edits by Code list for additional information.

Wearable Cardioverter Defibrillator

Oscillatory Chest Compression Devices

Bone growth stimulators

UMP is subject to HTA Decision – 20974, 20975, 20979, E0747, E0748, E0749, E0760

Continuous noninvasive glucose monitoring device

A9276, A9277, A9278, S1030, S1031

UMP is subject to HTA Decision for members under 19 years of age. 

Wheelchairs

E0983-4, E0986, E1002 - E1008, E1009 - E1010, E1220, E2230, E2295, E2300, E2301, E2310 - E2311, E2331, E2340 - E2343, E2609, E2610, E2617, K0005, K0009 - K0014, K0669, K0813 - K0816, K0820 - K0843, K0848 - K0864, K0868 - K0886, K0890 - K0891, K0898

Uniform Medical Plan – Pre-Authorization
Phone: 1 (888) 849-3682, Fax: 1 (877) 663-7526

UMP will follow Regence policy for many services, as long as Regence policy does not conflict with Washington State Health Technology Assessments (HTA) (PDF). For the Uniform Medical Plan, HTA decisions supersede Regence medical policy.

NOTE: Procedures denied due to an HTA decision will be member responsibility.

90875, 90876, 90901
Pre-authorization is required for diagnoses of Migraines and Tension Headaches; Biofeedback is not a payable benefit for other diagnoses.

Endometrial Ablation

Extracranial Carotid Angioplasty / Stenting

Hip resurfacing

UMP is subject to HTA Decision – Applicable unlisted codes and 27299

Implantable infusion pumps

UMP is subject to HTA Decision – C1772, C1891, C2626, E0782, E0783, E0785, E0786

77301, 77338, 77418, 0073T
Please reference the following Regence Medical Policies for further information:

• IMRT of the Breast and Lung
• IMRT of the Prostate
• IMRT of the Head and Neck Cancers and Thyroid Cancer
• IMRT of the Abdomen and Pelvis

UMP is subject to HTA Decision

Bi-compartmental partial Knee Replacement (medial or lateral AND patellofemoral) is not a payable benefit with UMP.

Obesity surgery

UMP utilizes an obesity management program, with services being coordinated between Regence, Accomplish Bariatric Nutrition Services, designated Centers of Excellence, and in some cases, designated physicians.

43644, 43770, 43771, 43772, 43773, 43774, 43846, 43848, 43886, 43887, 43888, S2083

Benefits for obesity surgery for children and members age 18-20 are subject to HTA Decision.

Orthognathic surgery

21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21230, S8262

Effective May 1, 2012:
21085, 21110, 21188, 21208, 21209, 21210, 21215

Sleep apnea surgery

Please refer to the Regence Clinical Edits by Code list for potentially investigational procedures.

Stents, Drug Coated or Drug-Eluting (DES)

UMP is subject to HTA Decision – G0290, G0291, 92980, 92981

Spinal surgery: Artificial intervertebral disc surgery

UMP is subject to HTA Decision – 22856, 22857, 22861, 22862, 22864, 22865, 0092T, 0095T, 0163T, 0164T, 0165T

22551, 22554: Regence uses Milliman Care Guideline (ORG S-320) as the basis for determining medical necessity. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.

Regence uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Regence at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.

• 21010 - Milliman Care Guideline A‐0522
• 21050 - Milliman Care Guideline A‐0521
• 29800, 29804 - Milliman Care Guideline A‐0492
• 21240, 21242, 21243 - Milliman Care Guideline A‐0523

Transplants, ventricular assist devices and total artificial hearts (pre-authorization not required for corneal and kidney transplants)

Transplants
G0341, G0342, G0343, S2053, S2054, S2055, S2060, S2065, S2140, S2142,S2150, S2152, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38230, 38232, 38240, 38241, 38242, 44135, 47135, 47136, 48160, 48554, 0141T, 0142T, 0143T

Ventricular assist devices and total artificial hearts
33975, 33976, 33977, 33978, 33979, 0048T, 0050T, 0051T, 0052T, 0053T

Vagal nerve stimulation

UMP is subject to HTA Decision – 61885, 61886, 61888, 64553, 64573, 95974, 95975, L8680, L8681, L8682, L8683, L8685, L8686, L8687, L8688, L8689

Varicose vein treatment

Please refer to the Regence Clinical Edits by Code list for medical necessity review codes and potentially investigational procedures.

UMP has a separate vendor – Washington State Rx Services – for their prescription drug benefit. Pre-authorization is necessary for certain injectable drugs that are not normally approved for self-administration when obtained through a retail pharmacy or a network mail-order pharmacy (these drugs are indicated on the UMP Preferred Drug List).