Federal Employee Program observation conversion for musculoskeletal cases (MAC)
Effective with dates of service on or after April 1, 2023, the Federal Employee Program® (FEP) with Anthem Blue Cross and Blue Shield (Anthem) will refer the following procedures for observation stay instead of full inpatient admission. These services will require prior authorization to determine medical necessity prior to rendering the service for Anthem federal employee members.
For services that are scheduled to begin on or after April 1, 2023, all providers must be aware that for the following procedures, FEP will be approving observation stay versus inpatient stay when medically appropriate:
- Knee arthroplasty (total/partial/revision knee)
- Shoulder arthroplasty (hemi arthroplasty/arthroscopy)
- Hip arthroplasty (total/partial/revision hip replacement) and hip arthroscopy
- Cervical fusion (anterior)
- Cervical discectomy or microdiscectomy, foraminotomy, and laminotomy
- Lumbar discectomy, foraminotomy, and/or laminotomy
- Small joint surgeries of the foot and ankle
- Reconstruction midface, LeFort I-III
- Sacral-Iliac fusion
How to submit a request for review
Starting March 13, 2023, providers can begin submitting requests for review with dates of service on or after April 1, 2023.
To reach the FEP Utilization Management (UM) department to submit an authorization request, providers may call our department directly, fax a request, or submit a request via Availity Essentials* with clinical information:
- Phone number:800-860-2156
- Chat: To chat with an FEP UM representative, go to: availity.com. Select Payer Spaces, select Federal Employee Plan, and access the chat through Chat with Payer.
We value your participation in our network, as well as the services you provide. We look forward to working with you to help improve the health of our members.
January 2023 Anthem Provider News - Georgia