Policies and Guidelines
Find important information on Independence Blue Cross policies and guidelines that best apply to you. If you have additional questions and need assistance, please call our support team at 1-888-475-6206.
- Benefits that Require Preapproval
- Specialty Medical Benefit Drugs Requiring Precertification
- Inpatient Hospital Stays
- Utilization Review
- Continuity of Care
- Emergency Services
- Complaints and Grievances
- Procedures that Support Safe Prescribing
- Preventive Drugs For Adults and Children
- Benefits Exclusions
Benefits that Require Preapproval
When you need health care services that require preapproval, your primary care physician or provider contacts the Clinical Services team and provides information to support the request for services. The Clinical Services team, made up of physicians and nurses, evaluates the proposed plan of care for payment of benefits. The Clinical Services team notifies your physician/provider if the services are approved for coverage. If the Clinical Services team does not have sufficient information or the information evaluated does not support coverage under your health plan, you and your physician/provider are notified in writing of the decision. Members and providers acting on behalf of a member may appeal the decision. At any time during the evaluation process or the appeal, the provider or member may provide additional information to support the request.
Services that require preapproval include, but are not limited to:
- Inpatient services
- Surgical and nonsurgical inpatient admissions
- Acute rehabilitation
- Skilled nursing facility
- Inpatient hospice
- Outpatient facility/office services (other than inpatient)
- Cataract surgery
- Cochlear implant surgery
- Comprehensive outpatient pain management programs (including epidural injections)
- CT/CTA scan
- Day rehabilitation programs
- Dental services as a result of accidental injury
- Hyperbaric oxygen
- Nasal surgery for submucous resection and septoplasty
- Nuclear cardiac studies
- Obesity surgery
- PET scans
- Pain management procedures (including epidural injections, transforaminal epidural injections, paravertebral facet joint injections)
- Transplants (except cornea)
- Uvulopalatopharyngoplasty (including laser-assisted)
- All home-care services (including infusion therapy in the home)
- Infusion therapy drugs in an outpatient facility or in a professional provider’s office (see list included in your subscriber agreement)
- Maternity admission and birthing center (prenotification requested only)*
- Elective (nonemergency) ambulance transport
- Prosthetics and orthotics – Purchase items (including repairs and replacements) over $500 (except ostomy supplies)
- Durable medical equipment – Purchase items (including repairs and replacements) over $500 and all rentals (except oxygen, diabetic supplies, and unit dose medication for nebulizer)
- Reconstructive procedures and potentially cosmetic procedures
- Breast: reconstruction, reduction, augmentation, mammoplasty, mastopexy, insertion, and removal of breast implants
- Chemical peels
- Excision of excessive skin and/or subcutaneous tissue
- Genetically and bio-engineered skin substitutes for wound care
- Hair transplant
- Injectable dermal fillers
- Keloid removal
- Lipectomy/liposuction, or any other fat removal procedure
- Orthognathic surgery procedures including but not limited to: bone graft, genioplasty, osteoplasty, mentoplasty, osteotomies
- Scar revision
- Skin closures including skin grafts, skin flaps, and tissue grafts
- Sex reassignment surgery
- Surgical treatment of gynecomastia
- Surgery for varicose veins including perforators and sclerotherapy
- Mental Health/Serious Mental Illness/Substance Abuse
- Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
- Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
- Biotechnology/Specialty Injectable Drugs (See list included in your open enrollment packet.)
- Covered services by a nonparticipating physician/provider for nonemergency services (in-network/referred care)*
* Applies to HMO plans only.
Specialty Medical Benefit Drugs Requiring Precertification
If you or your family members take specialty drugs, you may require precertification for these drugs before treatment begins. If you obtain services from an in-network provider, your doctor will take care of the paperwork. Members with Personal Choice® PPO who plan to obtain services from out-of-network providers are responsible for assuring that preapproval/precertification is obtained when necessary.
Inpatient Hospital Stays
During and after an approved hospital stay, the Independence Blue Cross Care Management and Coordination team monitors your stay. They review whether you are receiving medically appropriate care, see that a plan for your discharge is in place, and coordinate services that may be needed following discharge.
To assist Independence Blue Cross in making coverage determinations regarding the medical necessity and appropriateness of requested services, Independence Blue Cross uses medical guidelines based on clinically credible evidence. This is called utilization review. Utilization review can be done before a service is performed (prenotification/precertification/preservice), during a hospital stay (concurrent review), or after services have been performed (retrospective/post-service review). Independence Blue Cross follows applicable state/federal standards pertaining to how and when these reviews are performed.
Continuity of Care*
A provider is considered “terminated” when the provider’s contract with Independence Blue Cross expires and the provider is now considered out-of-network. Independence Blue Cross offers members continuation of coverage for an ongoing course of treatment with a terminated provider (for reasons other than cause) for up to 90 days from the date that Independence Blue Cross notified the member of the provider termination. Independence Blue Cross will cover such continuing treatment under the same terms and conditions as if the treatment was being received from participating providers.
If a member is in her second or third trimester of pregnancy at the time of the termination, the transitional period of authorization shall extend through post-partum care related to the delivery.
All authorized health care services provided during this transitional period would be covered by Independence Blue Cross under the same terms and conditions applicable for participating health care providers. The nonparticipating provider must agree that all authorized health care services provided during this transitional period would be covered by Independence Blue Cross under the same terms and conditions applicable for participating health care providers.
In order to initiate continuity of care, members must complete a Continuity of Care form and submit it to the Independence Blue Cross Care Management and Coordination department by following the instructions on the form. The form is available through Customer Service.
Nonparticipating health care providers (whose services are covered during the transitional period) must agree to be bound by the same terms and conditions as participating providers. The plan is not required to provide health care services that are not covered benefits.
* Continuity of care policy applies to HMO plans only.
An emergency is the sudden and unexpected onset of a medical or psychiatric condition manifesting itself in acute symptoms of sufficient severity or severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the member’s health or, in the case of a pregnant member, the health of the unborn child in jeopardy
- Serious impairment to bodily functions
- Dysfunction of any bodily organ or part
Emergency care includes covered services provided to a member in an emergency, including emergency transportation and related emergency services provided by a licensed ambulance service.
At Independence Blue Cross, protecting your privacy is very important to us. That is why we have taken numerous steps to see that your Protected Health Information (PHI) is kept confidential. Protected health information is individually identifiable health information about you. This information may be in oral, written, or electronic form. Independence Blue Cross may obtain or create your PHI while conducting our business of providing you with health care benefits.
Independence Blue Cross has implemented policies and procedures regarding the collection, use, and release or disclosure of PHI by and within our organization. We continually review our policies and monitor our business processes to make sure that your information is protected while assuring that the information is available as needed for the provision of health care services. For example, our procedures include steps to assist us in verifying the identity of someone calling to request PHI, procedures to limit who on our staff has access to your PHI, and directions to share only the minimum amount of information when PHI must be disclosed. We also protect any PHI transmitted electronically outside our organization by using only secure networks or by using encryption technology if the information is sent by email.
We do not use or share your PHI without your permission unless the law allows us to do so. Before using or disclosing your PHI for other purposes, we’ll obtain your written permission, also called an authorization. You may also direct us to share your PHI with someone you choose by giving us your written authorization. However, this authorization must include certain specific information in order to be valid. You may print a copy of our Authorization to Release Information form from our website, www.ibx.com, or request a copy by calling our Privacy Office at 215-241-4735.
Preventive Drugs For Adults and Children
As required by the Affordable Care Act, your Independence Blue Cross prescription drug plan includes certain preventive drugs without cost-sharing. Learn more about this coverage for preventive drugs for adults and children with the Independence Blue Cross health plan’s prescription drug benefit.
The benefits summaries available online and via mail represent only a partial listing of benefits and exclusions of the plans. Benefits and exclusions may be further defined by medical policy. This managed care plan may not cover all of your health care expenses. Read your contract carefully to determine which health care services are covered. If you need more information, please call 1-888-475-6206.
What’s not covered?
- Services not medically necessary
- Services or supplies that are experimental or investigative, except routine costs associated with qualifying clinical trials
- Hearing aids, hearing examinations/tests for the prescription/fitting of hearing aids, and cochlear electromagnetic hearing devices
- Assisted fertilization techniques, such as in vitro fertilization, GIFT, and ZIFT
- Reversal of voluntary sterilization
- Alternative therapies, such as acupuncture
- Routine adult eye care (except on PPO Platinum Complete and PPO Silver plans)
- Adult dental care, including dental implants or dentures, and nonsurgical treatment of temporomandibular joint syndrome (TMJ) (except on PPO Platinum Complete plan)
- Bariatric surgery
- Treatment of obesity
- Routine foot care, except for medically necessary treatment of peripheral vascular disease and/or peripheral neuropathic disease including, but not limited to, diabetes
- Foot orthotics, except for orthotics and podiatric appliances required for the prevention of complications associated with diabetes
- Routine physical exams for nonpreventive purposes, such as insurance or employment applications, college, or premarital examinations
- Contraceptive devices
- Immunizations for travel or employment
- Services or supplies payable under Workers’ compensation, motor vehicle insurance, or other legislation of similar purpose
- Cosmetic services/supplies
- Outpatient services that are not performed by your primary care physician’s designated provider
- Private duty nursing
- Orthoptic/pleoptic therapies
NOTE: Eligible dependent children are generally covered up to age 26. See contract for additional details.