Understanding a benefit plan?s precertification requirements is crucial for both members and providers. Because providers typically obtain precertification on behalf of members, it is important that they have easy access to information about these requirements. In the BlueCard^® environment, medical policy and precertification requirements are dictated by the Home Plan. Local providers may be unaware when the Home Plan?s medical policy or precertification requirements are different from the local Plan?s requirements.

Using the Medical Policy/Precertification Router

When using the Medical Policy/Precertification Router on the NaviNet^® web portal, you will be routed to the Home Plan?s website that contains medical policies and general precertification requirements. This transition happens seamlessly based on the prefix of the out-of-area member?s Plan, and it gives providers easy access to medical policy and precertification requirements. To view medical policy and precertification requirements for out-of-area Blue members, select BlueExchange^® Out of Area from the Independence Workflows menu, and then Medical Policy/PreCert Inquiry.

To conduct a search, select Medical Policy or Pre-Certification from the drop-down menu under ?Type of Inquiry.? Simply enter the prefix noted on the member?s ID card and select Submit.

The information that will be displayed is provided by the member?s Home Plan. If you have any questions regarding the information, please contact the member?s Home Plan.

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