WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 27 Part 4 Utilization Review Requirements To receive all of the coverage provided by your health plan, you must follow all of the requirements described in this section. Your coverage may be denied if you do not follow these requirements. Pre-Service Approval Requirements There are certain health care services or supplies that must be approved for you by Blue Cross Blue Shield HMO Blue. A health care provider who participates in your health care network should request a pre-service approval on your behalf. (You must request this review if the health care provider does not start the process for you.) For the pre-service review, Blue Cross Blue Shield HMO Blue will consider your health care provider to be your authorized representative. Blue Cross Blue Shield HMO Blue will tell you and your health care provider if coverage for a proposed service has been approved or if coverage has been denied. To check on the status of a request or to check for the outcome of a utilization review decision, you can call your health care provider or the Blue Cross Blue Shield HMO Blue customer service office. The toll free phone number to call is shown on your ID card. Remember, you should check with your health care provider before you receive services or supplies to make sure that your health care provider has received approval from Blue Cross Blue Shield HMO Blue when a pre-service approval is required. Otherwise, you will have to pay all charges for those health care services and/or supplies. (The requirements described below in this part do not apply to your covered services when Medicare is the primary coverage.) Referrals for Specialty Care You do not need a referral from your primary care provider or your attending physician in order for you to receive your health plan coverage. But, there are certain health care services and supplies that must be approved by Blue Cross Blue Shield HMO Blue before you receive them. (See below.) Pre-Service Review for Outpatient Services To receive all of your coverage for certain outpatient health services and supplies, you must obtain a pre-service approval from Blue Cross Blue Shield HMO Blue. A provider who participates in your health care network will request this approval on your behalf. During the pre-service review, Blue Cross Blue Shield HMO Blue will determine if your proposed health care services or supplies should be covered as medically necessary for your condition. Blue Cross Blue Shield HMO Blue will make this decision within two working days of the date that it receives all of the needed information from your health care provider. You must receive a pre-service approval from Blue Cross Blue Shield HMO Blue for:  Certain outpatient specialty care, procedures, services, and supplies. Some examples of services that may require prior approval include: some types of surgery; non-emergency ground ambulance; and certain outpatient treatment plans that require a review due to factors such as (but not limited to) the variability in length of treatment, the difficulty in predicting a standard length of treatment, the risk factors and provider discretion in determining treatment intensity compared to symptoms, the difficulty in measuring outcomes, or the variability in cost and quality. To find out if a treatment, service, or supply needs a pre-service review, you can check with your health care provider. You can also find out by calling the Blue Cross Blue Shield HMO Blue customer service office or using the online Blue Cross Blue Shield HMO Blue member self service option. To check online,