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Pre-certification / Pre-authorization Information


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.

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 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.

Procedures requiring prior authorization

NIA — 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 NIA at 1-877-642-0722. Radiology Management Reference Guide

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

Pharmacy prior authorization

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).