FPLIC / EPO Authorizations Self Funded 11/01/2011
FIRST PRIORITY LIFE INSURANCE COMPANY (FPLIC) PRECERTIFICATION REQUIREMENTS
Precertification determines medical necessity and is not a guarantee of payment by FPLIC. Payment is determined by the insured’s eligibility and benefits at the
time of service. Providers should check member eligibility and benefits prior to rendering the service.
Service Representatives – Traditional 1-888-827-7117
Precertification is required: 1-800-638-0505 Traditional
Service Representatives – PPO
1-866-262-5635
1-866-262-5623 PPO
Fax # 1-570-200-6788 (All Products)

Prior to Inpatient admissions for specific primary/admitting diagnoses. (See list)

Prior to Inpatient admissions to: Skilled Nursing Facilities, Rehabilitation Hospitals, all Non-participating Facilities.

For all Transplant surgeries AND select surgical procedures when performed on day of admission. (See list)

For Home Health Visits (except the visit following a mastectomy or maternity admission within time guidelines).

For Select CT scans (See list below)

Inpatient Behavioral Health Care Services for the following ICD-9 diagnosis codes: 290 – 319 require precertification. For Outpatient services please
verify precertification requirements by calling Community Behavioral Healthcare of Northeastern Pa (CBHNP) at 1-800-577-3742.

For Morbid Obesity surgery for the following codes. Patient must meet criteria before precertification is requested.
ICD-9 Codes: 43.82, 44.31, 44.38, 44.39, 44.5, 44.68, 44.69, 44.95 – 44.98
CPT Codes:
43644, 43645, 43770 – 43775, 43842, 43843, 43845 – 43848, 43886 – 43888

For Panniculectomy (any setting).

For Bony Impacted Wisdom Teeth removal in any setting EXCEPT the provider’s office.
HCPCS codes: D7230, D7240, D7241 ICD-9 Code: 23.19
Managed Pharmacy Program:
CPT code 15830, ICD-9 code 86.83
Fax # 1-570-200-6870
Phone # 1-800-722-4062

Home Infusion Services - TPN, Enteral nutrition, IVIG, anti-infective therapy

Refer to formulary for the current list of drugs requiring prior authorization – www.bcnepa.com
Revised 10-26-2011
CTA Scans Requiring Precertification:
Proc
Code
75571
75572
Description
Proc
Code
Computed tomography, heart, without contrast material, with
quantitative evaluation of coronary calcium
Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology (including 3D
image post processing, assessment or cardiac function, and
evaluation of venous structures, if performed)
75574
Description
Computed tomographic angiography, heart, coronary arteries and
bypass grafts (when present), with contrast material, including 3D
image post processing (including evaluation of cardiac structure and
morphology, assessment or cardiac function, and evaluation of
venous structures, if performed)
FPLIC / EPO Authorizations Self Funded 11/01/2011
FIRST PRIORITY LIFE INSURANCE COMPANY (FPLIC) PRECERTIFICATION REQUIREMENTS
1-800-638-0505 Traditional
1-866-262-5623 PPO 1-570-200-6788 Fax-All Products
Precertification is required for any of the following ICD-9 inpatient procedures, ONLY if performed on the day of admission:
Procedure Code
Description
Procedure Code
Description
00.51,00.54, 37.76 to 37.78, 37.94, 37.96 to
Pacemaker/AICD Defibrillators
51.23, 51.24
Laparoscopic Cholecystectomy
37.98, 39.64
00.55, 00.64, 00.65
Renal/Femoral/Iliac Stents
53.00 to 53.05, 53.10 to
Herniorrhaphy (Inguinal) (femoral)
53.31, 53.41, 53.42, 53.43,
(incisional or ventral) (Umbilical)
53.49, 53.51 to 53.69
(epigastric)
00.66
Percutaneous transluminal angioplasty(PTCA)
03.09, 03.6, 80.51, 84.60, 84.61
Laminectomy, Laminotomy, Discectomy
59.4 to 59.79, 78.69
Insertion or removal Uretheral
sling/suspension
06.02, 06.2, 06.3, 06.31,06.39, 06.4, 06.5,
Operations on thyroid and parathyroid glands
60.29
Prostatectomy (TURP)
06.50, 06.51, 06.52, 06.81, 06.89, 06.99
27.69
Palatopharyngoplasty
68.31
Hysterectomy, supracervical
33.21 to 33.24
Bronchoscopy
68.29, 69.19
Laparoscopy, myomectomy
34.22, 34.25
Mediastinoscopy
68.51, 68.59
Vaginal Hysterectomy
37.20, 37.26, 37.29
EPS Studies
70.50 to 70.55
Anteroposterior colporrhaphy and
repair
37.34, 37.78
Cardiac Ablations
70.50 to 70.55, 70.93
Cystocele/Rectocele Repairs
Revised 10-26-2011
44.66, 44.67
Laparoscopic Fundoplication/Fundoplasty
45.13, 45.16
47.01
EGD
Laparoscopic Appendectomy
51.10
ERCP
79.0 to 79.09, 79.10 to
79.19
83.63
92.30 to 92.32
Closed Reduction of Fractures
Rotator Cuff Repair
Stereotactic Computer Assisted
Volumetric Procedure
Precertification is required for any of the following diagnoses ONLY if it is the primary or admitting diagnosis:
Description
Abdominal Pain
Angina pectoris
Atrial fibrillation and flutter a pectoris
Cellulitis
Chest pain
Diagnosis Code
789.0 – 789.07, 789.09
413.0, 413.1, 413.9
427.31, 427.32
682.0 – 682.9
786.50, 786.51, 786.52, 786.59
Description
Hypertension
Diagnosis Code
401.0, 401.1, 401.9
Labyrinthitis
386.3 – 386.35
Nausea & Vomiting
Palpitations
Renal Colic/Kidney Stone
787.0 - 787.03
Concussion
Diabetes Mellitus
850.0, 850.9
250.0 −250.03, 250.9, 250.91 −250.93
Syncope and collapse
780.2
Dizziness/Giddiness
Gastroenteritis
Headache
Herniated disc, Lumbar Radiculopathy,
Medical back pain
Diagnosis Codes- 722, 722.0, 722.1,
722.2, 722.7, 722.10, 722.11, 722.70,
722.71, 722.72, 722.73
723, 723.0
724, 724.0, 724.1, 724.2, 724.3, 724.4,
724.5, 724.6, 724.00, 724.01, 724.02,
724.03 , 724.09
729.2
Revised 10-26-2011
785.1
592.0, 592.1, 592.9, 788.0
TIA
Urinary Tract Infection
Volume Depletion/Dehydration
Other Specified Cardiac Dysrhythmias
435.9
780.4
599.0
558.9
276.5, 276.50 – 276.52
307.81, 339.0-339.89, 346.0427.89
346.93,784.0
**Precertification is not required for these diagnosis codes if they are associated with the following surgical codes:
03.39, 03.4, 03.59, 77.29, 77.39, 78.59, 81.3, 81.00, 81.02, 81.03, 81.04, 81.05, 81.06, 81.07, 81.08, 81.30, 81.31,
81.32, 81.33, 81.34, 81.35, 81.36, 81.37, 81.38, 81.39, 81.62, 81.63