Citi Benefits Handbook
Precertification Requirements for Anthem BlueCross BlueShield Plans
You are required to obtain precertification for both in-network and out-of-network services. Your network doctor does not obtain precertification on your behalf.
Your plan reviews and determines whether hospitalization and non-emergency surgery are medically necessary.
In case of an unscheduled or emergency admission, you or your doctor must call your plan within two calendar days after the admission.
When traveling outside the United States, you are not required to obtain precertification for emergency hospitalization or other emergency services.
No benefits are payable unless Anthem BlueCross BlueShield determines that the services and supplies are covered under the plan.
You are required to obtain precertification for the following services:
- Inpatient admission;
- Maternity admission precertification only needed if inpatient stay exceeds 48 hours for normal delivery and 96 hours after a cesarean delivery;
- ABA — Applied Behavioral Analysis;
- Acute inpatient rehabilitation;
- Home health care (includes home infusion billed by Home Health Care agency);
- Visiting nurses;
- Private duty nursing (home);
- Skilled nursing facility (SNF);
- Hospice (inpatient and outpatient);
- Organ and tissue transplant (inpatient and outpatient);
- Bone marrow and stem cell transplant (inpatient and outpatient);
- Air ambulance (air ambulance only suspends for medical review, there is no penalty applied);
- Inpatient mental health/substance abuse (in-network/out-of-network);
- Residential mental health/substance abuse (if covered, precertification required in-network/out-of-network);
- In-network bariatric services;
- Gender reassignment surgery;
- Partial hospitalization mental health/substance abuse (in-network/out-of-network); and
- Some surgical procedures. Contact the Anthem Health Guide Service Team to determine whether or not your scheduled surgery requires precertification.
If you or your physician does not agree with Anthem BlueCross BlueShield's determination, you may appeal the decision. For more information about the claims appeal process, see "Claims and Appeals for Anthem BlueCross BlueShield Medical Plans" or call 1 (855) 593-8123.