Prospective Request (Pre-certification)
Prospective Request (Pre-certification) is the process by which the participant or the participant's health care provider provides information to BCBSWY to establish the medical appropriateness and necessity of specified services, prior to receiving care, in order to determine benefits for the service. Benefits will be denied if the participant is not eligible for coverage under the benefit plan on the date services are provided or if services received are not medically appropriate and necessary.
To request a prospective request (pre-certification), the participant or the health care provider must notify BCBSWY, in writing utilizing the Prospective Request (Pre-certification) Form, of the participant's intent to receive services requiring prospective review.
Participants must consult their applicable benefit plans or contact Member Services for specific coverage information. Contact information is located on the back of the participant's ID card.
Procedures Requiring Written Prospective Requests (Pre-certification)
The list below is a standard pre-certification review list. Some benefit plans have variations to the list. You may verify if prospective review is required for a service by contacting our Member Services Department at 1-800-442-2376. (This list is not all inclusive.)
- Ablation therapy (except endometrial)
- Assisted reproductive technology (i.e. GIFT, ZIFT, ICSI or IVF)
- Bone growth stimulator
- Botox Injections (Chemodenervation)
- Brachytherapy (Breast/Prostate/Uterine Radiation Seeds)
- Cardiac rehab
- Chronic pain management programs
- Cosmetic/Plastic Surgery:
- Reduction Mammoplasty/Breast Reconstruction
- Blepharoplasty/Laser Eye Surgery
- Dental anesthesia and hospitalization for all members age 6 and older
- DME (Wheelchairs/Hospital Beds/Power Equipment, etc.)
- Electroconvulsive shock wave therapy (ECT)
- EVLT, Phlebectomy, Sclerotherapy (vein surgery)
- Gamma knife procedures
- Genetic testing
- Growth Hormone therapy/treatment
- Hearing aids/Cochlear implants/Bone anchored devices
- Heart CT/Calcium scoring
- Hyperbaric Treatments
- Implantable drug pump
- Injectable drugs (other than insulin)
- Insulin infusion pump/Continuous glucose monitor
- Intradiscal Electrothermal Therapy (IDET)
- Lung volume reduction surgery
- Metal on metal joint resurfacing
- MRI of the breast
- Nasal sinus surgery
- Obstructive sleep apnea surgery & oral appliances
- Orthodontic services for the treatment of temporomandibular or craniomandibular joint disorders
- Osseo integrated implants
- Out of country services – all elective admissions and services received outside the United States
- Penile prosthesis
- PET scan
- Radiofrequency/Rhizotomy treatment
- Restricted Use Drugs
- Synagis injections
- UPPP (Uvulopalatopharyngoplasty)
- Virtual colonoscopy
- Weight loss prescription medications or drugs
- Weight loss surgery
Please contact our Case Management Department for benefits concerning the following services:
- Acute rehabilitation
- Bili lights/Bili blanket (Photo Therapy)
- Enteral feeding
- Home health care
- Home IV infusion
- Kid Care CHIP inpatient psych
- Long term care facility
- Negative pressure wound therapy (wound vac)
- Psychiatric or substance abuse admissions for residential treatment/hospitalization
- Skilled nursing facility (nursing home)
- TCU/Swing bed/Sub-acute/Extended care facility
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