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True Blue HMO Prior Authorizations


Provider Administrative Policy

Section
Provider Prior Authorizations
Policy Date
May 2008
Status/Date
Revised/February 2013

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

True Blue HMO Prior Authorizations

Contracting providers are responsible for obtaining the prior authorization on behalf of the member for the services shown below. Before rendering services, submit prior authorization requests via the  Blue Cross of Idaho website at bcidaho.com, fax, or mail to the Medicare Advantage care coordination team. For purposes of benefit payment, we reserve the right to review all directed care requests and approve, disapprove or modify these requests. The fact that a physician performs or recommends services, supplies or equipment accommodations does not conclusively constitute or establish them as medically necessary or as a covered benefit.

Confirmation of a provider`s contracting status is available on Blue Cross of Idaho’s website at bcidaho.com or by calling Blue Cross of Idaho Customer Service (see MA PAP102).

The following services require prior authorization:

  • All services provided by non-contracting providers

Medicare Advantage Prior Authorization Form 

Procedures 

Inpatient admissions - Prior authorization or Inpatient notification is required for all procedures listed on the CMS Inpatient Only list. If the inpatient procedure (such as a joint replacement) requires a separate authorization, both the procedure and the inpatient stay will require prior authorization. If the admission date is known at the time of the procedure authorization, we will review both authorization requests at the same time. If the admission date is not known when you submit the procedure authorization, the facility will be required to contact Blue Cross of Idaho before or at the time of inpatient admission.

For all other procedures, facilities must notify Blue Cross of Idaho of the inpatient admission when it is ordered and clinically indicated AFTER the standard post op recovery period. If a facility attempts to prior authorize an inpatient admission for a procedure that is not in the CMS inpatient only list,  we may not require the provider to submit a prior authorization request for the surgical procedure but will require an inpatient notification. Following a surgery, if the patient is not clinically stable and ready for discharge,the doctor can then make the decision to admit the patient and the facility must notify Blue Cross of Idaho of the inpatient admission.

Medications

Part B Drugs Requiring Prior Authorization

Self Administered Drugs

  • Blue Cross of Idaho Medicare Advantage plans must comply with the CMS requirements for self-administered drugs.  Effective January 1, 2009, we consider self-administered drugs non-covered Part B services. Providers may need to re-evaluate the use of these medications for their Medicare Advantage patients.  A complete list of these medications may be found at the following link: SAD Drugs

Durable Medical Equipment (DME)

  • CPAP/BIPAP
  • DME greater than $500 (including rental to purchase)
  • Home oxygen therapy
  • Orthotics and prosthetics greater than $500

Services - (select link for list of CPT codes, when available)

Category III Codes

  • Unless the service is listed as a covered service by the CMS National Coverage Determination or Local Coverage Determination, Blue Cross of Idaho Medicare Advantage will consider these codes as investigational and therefore, non-covered.

Diagnostic Studies

  • Advanced imaging (CT scans, MRI/ MRA, PET scans, nuclear cardiology, functional brain MRI and T codes including virtual colonoscopy, see MA PAP302 )

Clinical Trials

Prior Authorization Submission Requirements:

Elective Procedures
Elective procedures are subject to medical review, as previously listed, require medical records and may take up to 14 days to process. Please submit requests for planned surgical procedures 14 days prior to the procedure to allow time for review and coordination of services. If medical necessity justifies special handling, please include an explanation.

Retrospective Authorization
Retrospective authorization will not be accepted. If a provider does not obtain prior authorization before rendering services, the provider should submit a claim for processing. Upon denial, the provider may dispute the claim decision by formally requesting reconsideration. A reconsideration request must include supporting documentation.

Prior Authorization Request
Complete prior authorization requests include:

  • Member name, ID number and date of birth
  • Requesting provider name and number
  • Name and specialty of provider to whom the patient is referred
  • Date of appointment
  • Requested services (scope of services)
  • Name and phone number of staff member completing the form
  • Diagnosis (ICD-9-CM)
  • Procedure code (CPT®)
  • Remarks specific to this request

If a member’s condition is the result of an accident or work-related injury, please complete the appropriate area of the form with as much information as possible. The provider`s office is responsible for claim submission to labor and industry and other primary carriers directly.

Submit prior authorization request and all pertinent medical documentation to the Medicare Advantage care coordination team via:

  • Web site: bcidaho.com
  • Fax: 208-395-8204
  • Mail:Medicare Advantage Care Coordination Team
    Confidential
     
    P.O. Box 8406
    Boise, ID  83707

To request changes to an existing authorization, please contact the Medicare Advantage care coordination team (see MA PAP102 ).

Before providing any services to True Blue HMO members, be certain to have an approved authorization issued by the Medicare Advantage care coordination team. Services rendered without prior authorization may result in nonpayment of claims. Visit the Blue Cross of Idaho Web site at bcidaho.com to check prior authorization status.  Phone confirmation may be available from Medicare Advantage Customer Service before receiving written authorization.

Prior authorizations are limited to a specific period of time, number of visits or scope of services.

No prior authorization is required for emergency services in any setting.


Policy History

Date Action Reason
February 2013 Revised Language clarification mental health/substance abuse pa requirements/added link to form
September 2012 Revised Updated inpatient admissions to clarify the notification process
January 2010 Revised Links added for prior authorization codes
October 2009 Revised Removed vision prior authorizations and updated language
July 2009 Revised Formatting changes, link to MA PAP304 and additions to prior authorization list
March 2009 Revised Removed arthroscopies and added Category III codes and self administered drugs
November 2008 Revised Advanced imaging language added
May 2008 Revised Prior authorization additions

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