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2018 Blue Cross Medicare AdvantageSM Preauthorization Updates

December 1, 2017

Beginning Jan.1, 2018, providers will be required to obtain preauthorization through Blue Cross and Blue Shield of New Mexico (BCBSNM), DaVita Medical Group (DMG) or eviCore for certain procedures for Blue Cross Medicare Advantage members as noted below.

Services performed without benefit preauthorization may be denied for payment and in whole or in part, you may not seek reimbursement from members.

Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

A referral to an out-of-plan or out-of-network provider which is necessary due to network inadequacy or continuity of care must be reviewed by the BCBSNM Utilization Management or DMG (if the member is attributed to DMG this information will be reflected on the ID card) prior to a BCBSNM patient receiving care.

To obtain benefit preauthorization through BCBSNM for the care categories noted above, you may continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website.

Our goal is to provide our members with access to quality, cost-effective health care. If you have any questions, please contact your Network Management Consultant PDF Document.

Sincerely,

Network Management
Blue Cross and Blue Shield of New Mexico

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSNM

 

 


Prior Authorization rules - Medicare Medical / Surgical / Behavioral Health

PREAUTHORIZATION REQUIREMENTS through eviCore - Effective 01/01/2018

1. Cardiology
2. Radiology
3. Medical Oncology
4. Molecular Genetics
5. Musculoskeletal - (PT/OT/ST;Spine/Joint/Pain/Chiro)
6. Radiation Therapy
7. Sleep
8. Specialty Drug

Utilizing the eviCore Healthcare Web Portal is the most efficient way to initiate a case, check status, review guidelines, view authorizations / eligibility and more url: https://www.evicore.com/healthplan/bcbs  OR
Call toll-free at 855-252-1117 between 7 am -7 pm local time Monday through Friday except holidays.

Limitations Of Covered Benefits by Member Contract

This list is not exhaustive.  The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply.

Covered Service

Prior Authorization

Allergy care, including tests and serum

Please refer to the procedure code list for Authorization Requirements

Bariatric surgery

Yes

Blepharoplasty

Yes

Botox Injections

Yes

Chemotherapy and Radiation Therapy

Yes

Dental Care

Yes

DME - Medical supplies, Orthotics and Prosthesis      
(Any single durable medical equipment prosthetic and orthopedic device greater than $1500)

Please refer to the procedure code list for Authorization Requirements and Accumulated Annual limits without authorization

Ground and air ambulance

Ground - No

Air - Yes

Home health care and intravenous services

Please refer to the procedure code list for Authorization Requirements

Hospital services (inpatient, outpatient)

Please refer to the procedure code list for Authorization Requirements. Inpatient stays with services that are managed by eviCore will be reviewed through eviCore.

Hyperbaric Oxygen

Yes

Injections

Please refer to the procedure code list for Authorization Requirements

Implantable Devices

Yes

Laboratory, X-ray, EKGs, medical imaging services, and other diagnostic tests

Please refer to the procedure code list for Authorization Requirements

Long Term Acute Care (LTAC)

Yes

Minor surgeries

Please refer to the procedure code list for Authorization Requirements

Network Exceptions including Out of Plan or Out of Network (due to Network Adequacy)

Please refer to the procedure code list for Authorization Requirements

Nutritional counseling services

Please refer to the procedure code list for Authorization Requirements

Nutritional products and special medical foods

Yes

Office visits to PCPs or specialists, including dieticians, nurse practitioners, and physician assistants

No

Podiatry (foot and ankle) services

Yes

PET, MRA, MRI, and CT scans

Please refer to the procedure code list for Authorization Requirements

Routine physicals

No

Second opinions (in network)

No

Skilled Nursing Facilities

Yes

Special rehabilitation services, such as: physical therapy, occupational therapy, speech therapy, cardiac rehabilitation, pulmonary rehabilitation

Yes, Please refer to the procedure code list for Authorization Requirements

Surgery, including pre-and post-operative care: assistant surgeon, anesthesiologist, organ transplants

Please refer to the procedure code list for Authorization Requirements; all transplants and pre-transplant evaluation require prior authorization

Intersex Reassignment Surgery
55970, 55980

Yes

Summary of Services and Behavioral Health UM requirements
*Providers requesting services for Texas Medicare Advantage HMO Plans should contact Magellan for authorization requirements

Covered Service

Prior Authorization

All Inpatient Stays Facilities/Hospitals

Yes

All Network Exceptions

Yes

Covered Service

Prior Authorization

Partial Hospitalization

Yes

Psychological/Neuropsychological Testing

Please refer to the procedure code list for Authorization Requirements

Electroconvulsive Therapy

Yes

Transcranial Magnetic Stimulation

Yes

Outpatient Services

Please refer to the procedure code list for Authorization Requirements