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FEP does not provide for the predetermination of benefits. However, a new feature has been added,
the FEP Pre-Service review, as an expanded customer service function. This function allows the hospital,
physician or other provider of medical services to obtain a guarantee of benefits on certain procedures
or equipment prior to a claim being filed for service.
The Pre-Service feature allows claims to process more quickly, since there is already a guarantee of
benefits on the FEP files. However, in order for the benefit guarantee to be "upheld", the information
submitted on the actual claim must match with the information that is given during the Pre-Service call.
Otherwise, the claim will be remanded to the more rigorous claims processing review for benefits and medical necessity.
The factors in benefit determination are as follows:
- Eligibility of the member when the service was performed
- Provider of Service, i.e., Hospital, Physician or Other Provider of Service
- Status of Hospital, Physician or Other Provider of Service (Preferred or Non-Participating)
- Place of Service (Home, Office, Hospital/Facility)
- Diagnosis
- Procedure Code
Pre-Service Review is limited to specific services including:
- Home Infusion
- Home Health Care
- Ambulance Transport
- High Dollar DME ($500 or more)
- Gastric Bypass Surgery
- Reduction Mammoplasty
- Septoplasty
- Cosmetic Procedures
- Vein Ligation
- Wound Vac (Initial Review for Home Use)
HOW TO OBTAIN AN FEP PRE-SERVICE REVIEW:
Call (Note: Pre-service must be obtained by a hospital, physician or provider of
other medical services, only. Subscribers/members should not be advised to call.)
FEP Pre-Service Department: 1-866-697-9696 or Fax to 973-466-5599
- (FEP Customer Service at 1-800-664-2583 can also route your call to the Pre-Service Department)
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