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Prior Authorization/Precertification

Prior Authorization/Precertification

What is Prior Authorization/Precertification?

According to HealthCare.gov, Prior Authorization is, “A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.”

Prior Authorization, Preauthorization, and Precertification: What’s the difference?

These words are all considered industry standard terms for the same process and can all be used interchangeably to describe the act of verifying various methods of care through your insurer.

Why Prior Authorization?

For hospital admissions, some outpatient procedures, and some medications, Nippon Life Benefits requires prior authorization. This process helps to reduce unnecessary medical expenses and ensure coverage is available should you or a family member require inpatient or outpatient care.

Depending on your benefit program, failure to obtain prior authorization may result in reduced benefits. Please check your benefit booklet-certificate for details. Your benefit booklet-certificate can be found on the member portal. Keep in mind that all eligible services are subject to medical necessity requirements and plan provisions.

If you or a family member are in need of care, members should call the number located on the back of their benefits card.

List of Services

Contact Customer Service to Confirm Coverage: 800-374-1835

Outpatient Services Codes
Diagnostics
CT Head or Brain 70450, 70460, 70470
CT Maxillofacial 70486, 70487, 70488
CT Orbit, Sella or Posterior Fossa or Outer, Middle or Inner Ear 70480, 70481, 70482
CT Soft Tissue Neck 70490, 70491, 70492
MRA Head 70544, 70545, 70546
MRA Neck 70547, 70548, 70549
MRI Lower Extremity 73718, 73719, 73720, 73721, 73722, 73723
PET Scan Limited, and Whole Body 78811, 78812, 78813, 78814, 78815, 78816
IMRT 77301, 77338, 77385, 77386, 77387, G6015
Bariatrics Procedures
Bariatric Surgery 43644, 43645
Lap Band, Gastric Sleeve 43770-43775
Gastric Bypass - Lap Band 43842-43865
Breast Related Procedures
Breast- Mastectomy 19301-19307
Breast- Reduction Mammaplasty 19318, 19316, 19324, 19325
Breast- Removal of Mammary Implant or Delayed Insertion 19328, 19330, 19340, 19342
Breast- Reconstruction 19350, 19355, 19357-19369, 19370, 19371, 19380, 19396
Selected Procedures
Hysterectomy 58150-58294
Laparoscopic Hysterectomy 58541-58544, 58548-58554, 58570-58573, 58575
Abdominoplasty, Panniculectomy 15830-15839
Blepharoplasty 15820-15823
Blepharoplasty - Repair of Blepharoptosis 67900-67924
Septoplasty - Nasal 30520
Rhinoplasty- If Secondary to Septoplasty 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465
Orthopedic Procedures
Artificial Disc Lumbar 22856-22865
Artificial Disc Cervical 0095T-0098T, 0163T-0165T
Back Surgery- Spinal Cath with Lami 62351
Back Surgery- Laminectomy Cerv Decomp 63001
Back Surgery- Laminectomy Thor Decomp 63003
Laser Discectomy, Radiofrequency Decomp. 62287
Back Surgery - Laminectomy 63005, 63011, 63012, 63045-63048, 63050-63066, 63173-63200
Back Surgery - Laminectomy-Dec of Cord 63015-63042, 63043, 63044
Back Surgery - Spine Disk Surgery 63075-63078
Back Surgery - Removal of Vertebral Body 63081-63103
Back Surgery - Lami Myelotomy 63170-63172
Back Surgery - Lami excision Lesion Tumor 63250-63275
Back Surgery - Lami excision Lesion 63276-63290, 63295, 63300-63308
Back Surgery - Laminectomy Implnt Neurst 63650-63688
Percutaneous Intradiscal Electrothermal Annuloplasty 22526, 22527
Back Surgery - Lateral discectomy-Thoracic 22532
Back Surgery - Lateral discectomy-Lumbar 22533, 22534
Back Surgery - Cervical transoral- C1-2 22548, 22551, 22552
Back Surgery - Ant Cervical below C2 22554
Back Surgery - Anterior-Thoracic 22556
Back Surgery - Anterior Lumbar Fusion 22558, 22585, 22586
Back Surgery - Post or postlat Cervical Fusion 22590, 22595, 22600
Back Surgery - Post Thoracic Fusion 22610
Back Surgery - Post Lumbar Fusion 22612-22614
Back Surgery - Post Laminectomy/discect 22630, 22632, 22633, 22634, 22800-22819
Back Surgery - Exploration of Spinal Fusion 22830
Facet Joint Injection 64490-64495
Radiosurgery Procedures
Crainio Stereotatic Radiosurgery 61790-61800
Sterotactic Radiosurgery 63610-63621, 63600, 77432-77470
Vericose Vein Procedures
Sclerotherapy 36468-36471
Venous Ablation 36473-36479
Venous Ligation 37700-37785


This material and information is intended for informational purposes only. This material and information is subject to change, at any time and without notice, by Nippon Life Insurance Company of America.

Frequently Asked Questions

  1. I have an upcoming outpatient procedure, what do I do?
    Outpatient services requiring prior authorization/precertification generally include the following: Complex imaging, certain cosmetic/reconstructive surgery and back surgery. For a current list of outpatient services requiring prior authorization/precertification, please see the Nippon Life Benefits website at (www.nipponlifebenefits.com). We ask your provider to contact us 15 days prior to the procedure being performed. The number to contact is 877-518-0770.

  2. What if my procedure is urgent and I don’t have 15 days to wait for an approval?
    Nippon Life Benefits can review on an expedited basis if all the required information is received. Please be aware that approvals are based on medical necessity and if a procedure is done prior to a medical review, your claim may be denied for additional information or for medical necessity.

  3. What if I have a procedure scheduled for the first week after the plan anniversary/renewal?
    Clients will receive information related to the outpatient precertification/prior authorization process 45 days prior to plan anniversary/renewal, to share with members. Members will receive new ID cards prior to the plan anniversary/renewal to reflect the new requirement.

  4. Do services rendered in a physician’s office require prior authorization/precertification?
    Yes, all outpatient services listed require prior authorization/precertification regardless of where the service is rendered.

  5. I wasn’t aware that outpatient prior authorization/precertification was required as I don’t see anything listed in my booklet?
    Outpatient prior authorization/precertification is a new service that Nippon Life Benefits is offering on your plan anniversary date starting 1/1/2021. Please consult with your employer for your effective date.

  6. Can the outpatient prior authorization/precertification process be completed by telephone?
    Yes, the process can be completed by telephone as long as all the required information from the provider is received.

  7. Is there a specific form that needs to be completed?
    No, there is no specific form that needs to be completed.

  8. How will I know if my outpatient service has been approved?
    A letter will be mailed to the provider, facility and member outlining the decision of the review.

  9. What are the next steps if my procedure has been denied?
    You have the right to appeal the decision. The appeal process will be outlined in the denial letter that is sent to the provider, facility and member. You can also refer to your booklet for your individual appeal rights.

Non-Emergency Stays

You, a family member, your doctor, or facility must call the Precertification number on the back of your ID card prior to any stay. Please be prepared to provide your benefits program ID number, the patient’s name, a reason for admission, the date of expected admissions, the doctor’s name and phone number, and the facility’s name and phone number. The utilization review staff considers the patient’s condition and proposed treatment plan to determine the number of days authorized for stay.

Emergencies

If you or a family member is admitted due to an emergency, you must call the precertification number on the back of your ID card within two working days of admission.

Maternity Delivery

New mothers and newborns receive automatic authorization for a minimum 48-hour stay including the day of delivery for a normal delivery or a minimum 96-hour stay including day of delivery for a caesarian section. If a longer stay is medically necessary, the patient or their representative must call before the end of the authorized time frame.

Please Note: The member or the provider can call for prior authorization.

Drug Formulary


State-Specific Drug Listings

Specific Drug Listings for Illinois Group Contracts:


Specific Drug Listings for Texas Group Contracts:

Disclaimer

This information is subject to change, at any time and without notice, by Nippon Life Insurance Company of America. Further, the policies and procedures summarized herein may vary based upon your policy situs state and/or state of residence. Please contact Customer Service for additional details.

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