Pre-certification / Pre-notification

Preadmission certification or pre-certification is a process where a member must call and receive prior approval for an admission into any hospital. Failure to receive preadmission certification usually involves a penalty payment by the member of a specified dollar amount – varies by plan design. Arkansas Blue Cross and Blue Shield no longer requires preadmission certification.

Pre-notification is a process where a member should call in prior to admission to an out-of-network hospital facility or a hospital outside the state of Arkansas to alert us of the admission. Pre-notification provides information helping to determine if case management would be an appropriate option for the member. Pre-notification is not required for outpatient treatment or any in-state, in-network inpatient admissions.

If the inpatient admission does not fall within the described exceptions previously mentioned, the policy may require pre-notification. You or the patient would need to contact Arkansas Blue Cross and Blue Shield by calling the Customer Service number on the back of the member's ID card.

Pre-authorization / Prior authorization:

Prior authorization or pre-authorization is a review prior to the time a specified procedure is scheduled. This review consists of checking clinical documentation to verify the medical necessity for the procedure. The review is done by Carelon Medical Benefits Management and Lucet based on medical guidelines from Arkansas Blue Cross and Blue Shield. A prior authorization is required for each different procedure, even if those procedures are performed on the same day. Failure to obtain prior authorization will result in denial of the claim.

Procedures requiring prior authorization:

Carelon Medical Benefits Management — Specified high tech radiology procedures, MRI's, CT's, PET scans, and nuclear cardiology, must have prior authorization. Inpatient services, emergency room services and observation room services are not subject to this review. For prior authorization, call Carelon at 877-642-0722.

Lucet (Still applies if insurance is secondary payor) —

• Inpatient stays
• Emergency admission (next business day)
• Partial hospitalization program
• Intensive outpatient program

For any assistance, call the customer service at 800-238-8379. Provider calls from Texarkana inquiring about the need for prior authorization should call 877-642-0722

Pharmacy prior authorization:

Please contact CVS Caremark at 877-433-2973 (Monday — Friday from 8 a.m. — 6 p.m. CST) to request approval for a prescription drug that requires a prior authorization. Exceptions for 1) prescription drug fertility treatments, 2) dosages in excess of the plan’s quantity limits, 3) step therapy, and 4) drugs not covered by the plan are handled by the plan and can be requested by calling 501-378-3392 (Monday — Friday from 8 am — 4:30 pm CST).