Skip to main content
Share |

Date-of-Service/Historical Search
Select a date from the calendar.
Enter or choose a date. Leave blank to see all historical content for this page.

 
     
 

State Employee PPO - Preferred Patient Care

Copay and/or Deductible & Coinsurance Based Plan

Listed below are the UM requirements in accordance with the terms of your Preferred Patient Care provider agreement. If a service is not listed below, there was not a contractual obligation identified; however, this page is designed to provide general guidelines for this line of business. Benefits vary according to the terms of the member contract. Check Availity for your member's specific guidelines.  

Please access Medical Policies (Medical Coverage Guidelines) for supporting information regarding the criteria used in determining coverage for payment purposes. All services must meet the definition of medical necessity as outlined in the Member's benefit contract. Although a service may not require an authorization it is still required to meet the definition of medical necessity and is subject to medical necessity review pre-service, post-service or concurrently.

Service Contractual Obligation
Advanced Imaging
(CT Scans, MRIs/MRAs, PET Scans, Nuclear Medicine)
Authorization, certification, or notification not required; however, VPCR is available.
Chemotherapy/Radiation Therapy Prior approval required if participating in the PADP. Refer to ICORE at www.icorehealthcare.com.
Home Health No authorization, certification or notification required.
Hospice No authorization, certification or notification required.
Injectable Medication
 Prior authorization is required and is managed by our specialty pharmacy, Express Scripts.  
Inpatient
(Acute, Psych, Substance and LTAC)

Preadmission certification is required for acute care, LTAC, psychiatric and substance hospitals, including change from observation to inpatient status .

  • Penalty is 20 percent of the allowed amount, not to exceed $500.
  • Exceptions are:
    • When Medicare A is primary
    • VA hospitals
    • Out of country hospitals
Laboratory

Quest Diagnostics and Ameripath are Florida Blue's preferred laboratory and anatomical pathology provider.  The preferred lab for dermatopathology services is  Dermpath Diagnostics. 

Services referred to non-participating laboratories may result in higher out-of-pocket cost for the member.

Pharmacy
 Managed by Medco
Pharmacy
(Provider Administered)
PADP applies
Surgical Procedures  Authorization, certification, or notification is not required.

VPCR is available

Potentially cosmetic, plastic, or reconstructive surgery is subject to medical necessity review.

Transplant Services
(excluding office visit)
Prior benefit determination must be obtained for all transplants, except for kidney or cornea. Contact the State Employees' PPO Plan customer service to determine if benefit applies.
6/25/2014
The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

Refer to the References section to view all applicable copyrights, registered trademarks, service marks, and/or references. Acronyms are also defined in the References section.

Internet Privacy Statement

© 2012 Florida Blue is a trade name of Blue Cross and Blue Shield of Florida Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.