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Medical Necessity Reviews for Non Authorized Services


Provider Administrative Policy

Section
General Information
Policy Date
June 2011
Status/Date
Revised/September 2011
Provider Type(s)
All Providers  

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

Medical Necessity Reviews for Non Authorized Services

Certain services require prior authorization as defined by Provider Administrative Policies. When a provider fails to obtain prior authorization and provides the services despite the requirement, Blue Cross of Idaho may deny the resulting claim. If a provider presents an acceptable explanation of the circumstances that led him to neglect obtaining the  prior authorization, Blue Cross of Idaho may grant the provider a post claim, medical necessity review. Medical necessity reviews for providers who fail to obtain a prior authorization are not the norm, but may be allowed for providers who historically demonstrate a pattern of compliance with prior authorization requirements and provide an acceptable (as determined by Blue Cross of Idaho) explanation of why they did not obtain prior authorization for the current claim.

Blue Cross of Idaho will identify providers who demonstrate a pattern of non-compliance for obtaining prior authorizations and once identified, those providers may not be eligible for future consideration or medical necessity reviews.

The following are examples of circumstances that may qualify for a medical necessity review under this policy:

  • If a patient receives an advanced imaging study within the 24 hours immediately following an ER visit as ordered by an emergency room physician.
  • If a provider indicates the patient presented the wrong insurance card and the provider was not aware the patient had Blue Cross of Idaho. (This may occur when the member is newly enrolled in the Blue Cross of Idaho plan or the member hasn’t visited that practice since his new enrollment).
  • If a provider is a new Blue Cross of Idaho contractor and has only seen a small volume of Blue Cross of Idaho members.
  • If a provider presents a remittance advice from another insurance carrier demonstrating an assumption that another payer was primary.
  • If Blue Cross of Idaho denies a claim for a service that was not on our current Web list of services requiring prior authorization.
  • When there is less than a two-week gap for physical, occupational or speech therapy authorization for the same member under a given provider, an inquiry from the provider will allow us to close that two-week gap.
  • If an inquiry relates to a claim that totals $300 or less in allowances, and the provider does not have a history of non-compliance with prior authorization requirements.

The above list is not intended to be an all-inclusive list of reasons that qualify a claim for a medical necessity review.

If you have questions about which services require authorization or how the process works, please contact your provider relations representative. If you demonstrate a pattern of non-compliance with prior authorization requirements, your provider relations representative may contact you and Blue Cross of Idaho may reject future claim inquiries.

A non-contracting provider cannot initiate an inquiry or appeal on behalf of a member unless they sign and return the CMS Waiver of Liability Statement. Completed waivers can be faxed to 208-286-3559.

CMS Waiver of Liability Statement

Another option for providers attempting to act on behalf of their patients, is to have the patient sign the CMS Appointment of Representative form which essentially signs their appeal rights over to a representative. This completed form can also be faxed to 208-286-3559.

CMS Appointment of Representative


Policy History

Date Action Reason
September 2011 Revised Waiver of Liability and CMS Appointment of Representative forms added.

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