Employers

Group Administrator's Manual

Hospital Admission Pre-Certification/Pre-Notification Requirements

Admission Pre-Certification Requirements for Arkansas Blue Cross and Blue Shield and its Affiliates

Product Line Inpatient PreCertification and Continued Stay Review Inpatient PreCertification Outpatient Pre-Certification
Arkansas Blue Cross and Blue Shield Not Required
Exception: FEP
Required for all out of network and out of state admissions. Not Required
Federal Employee Program (FEP) Required
Please Note: All FEP cards have an Arkansas Blue Cross logo and ID numbers begin with "R"
  Not Required
Health Advantage Not Required Required for all out of network and out of state admissions Not Required
BlueAdvantage Administrators of Arkansas Refer to customer service as self insured employer groups have different requirements Refer to customer service as employer groups have different requirements Refer to customer service as employer groups have different requirements
USAble Mutual Not Required Required for all out of network and out of state admissions Not Required

If you have questions regarding pre-certification requirements for any member for any of our products, please call the customer service number on the back of the member's ID card.

Definitions

Admission Pre-certification — The process of evaluating the appropriateness of an admission against established medical necessity criteria and assignment of initial length of stay at the time of admission into an acute care facility or at the time of notification by the facility of the member’s admission.

Continued Stay Review — The process of evaluating the appropriateness of continued inpatient stay during the inpatient confinement.

Admission Pre-notification — Notification of the hospital admission only. No medical necessity review is required.

Outpatient Pre-certification — The process of evaluating the appropriateness of an outpatient procedure/service against established necessity criteria.

Necessity Criteria — Approved criteria, which includes nationally recognized medical necessity review criteria.

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