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.
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 National
Imaging Associates (NIA) and New Directions 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.
For any assistance, call the customer service at 1-800-238-8379. Provider calls
from Texarkana inquiring about the need for prior authorization should call 1-877-642-0722
Please contact CVS Caremark at 1-877-433-2973 (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).
Health Advantage is an Independent Licensee of the Blue Cross and Blue Shield Association and is licensed to offer health plans in all 75 counties in Arkansas. Copyright © 2002-2017 HMO Partners, Inc.