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Musculoskeletal Preauthorization Program Effective February 1, 2019

As previously announced, Excellus BlueCross BlueShield will soon launch a Musculoskeletal Preauthorization Program. The program will begin with requests for preauthorization for dates of service on or after February 1, 2019. The program will apply to commercial, Medicare Advantage and Essential Plan lines of business when the member benefit requires preauthorization.

The musculoskeletal program will be administered in partnership with eviCore healthcare, a specialty medical benefits management company that provides utilization management services for health plans. As you may be aware, Excellus BCBS has retained eviCore to manage other specialized programs since 2007.

The following are important details you will need to know in preparation for the start of our musculoskeletal program:

Preauthorization Requirements

  • Effective February 1, 2019, the following procedures will require clinical review regardless of place of service:
    • Joint;
    • Interventional pain;
    • Spine services
  • The list of CPT codes for services requiring preauthorization will be available in the Authorizations section of our website on January 21. As with previous updates, newly released CPT codes and HCPCS will be added for services already on the list. Newly added codes will be shaded in gray on the preauthorization code list posted on our provider website.
  • To review our medical policies regarding musculoskeletal procedures, go to Provider.ExcellusBCBS.com
  • eviCore’s phone lines and Web portal will open on Monday, January 21, to accommodate preauthorization requests for dates of service on or after February 1.
  • The Clear Coverage™ tool will no longer be available beginning Monday, January 21 for preauthorization requests pertaining to musculoskeletal services for commercial, fully insured and Medicare Advantage members. Clear Coverage will remain available for our commercial self-insured line of business, only.
  • It is the responsibility of the ordering physician to obtain preauthorization.
  • We recommend that the rendering provider verify that the authorization has been obtained.

Process for Requesting Preauthorization

  • To enter a preauthorization request, contact eviCore via either of the following:
    • www.evicore.com
    • Phone: 1-888-333-9036, 7 a.m. to 7 p.m. EST, Monday through Friday.
  • The following information is necessary to request preauthorization:
    • Musculoskeletal procedure requested;
    • Patient, ordering provider and rendering provider (if different);
    • Intended place of service;
    • Clinical information including past medical history, recent test results, prior/ongoing treatments and their effects, and current clinical condition;
    • Date and location of surgery.

Clinical Review Process

  • Requests will be reviewed by eviCore’s board-certified physicians from the appropriate specialty using criteria that is aligned with national specialty society guidelines and accepted clinical literature.
  • Add-on procedures are eligible for reimbursement and reviewable under the primary procedure when an approval for the primary procedure is on file.
  • Clinically urgent requests occurring during regular business hours should be initiated by phone. Once a case has been deemed clinically urgent, the decision will be expedited upon receipt of all clinical information.
  • Late preauthorization will be allowed within two business days only if the case is considered clinically urgent or occurs after business hours.
  • Clinical review preauthorization is not required for inpatient emergency; however, notification to the health plan is required for the inpatient admission as per our member contract requirements or your facility participation agreement.
  • Remember, as always, that failure to obtain preauthorization or to comply with your participation agreement or our member contract requirements, or utilization management policies and procedures may result in a claim denial.
  • For pain management requests, only one injection will be approved up front by eviCore. If additional injections are needed, a concurrent review will be conducted by the Health Plan.
  • For joint and spine surgeries, discharge summaries from physical therapy will be required to review for medical necessity.

Approvals/Denials

  • Most preauthorization determinations are made on first contact. If a preauthorization is initiated online and the request meets criteria, the service will be approved within regulatory time frames, usually the same day depending on the time the request is made, and a time-stamped approval will be available for printing.
  • Approvals/denials will be relayed by eviCore to the member and practitioner in writing and by phone call.
  • Please contact eviCore to request revisions to approved services; these revisions may result in a new medical necessity review
  • If a treatment plan is partially denied, or fully denied, the ordering physician can initiate a peer-to-peer discussion with a board-certified eviCore specialist. Request to speak to a specialist by calling eviCore at 1-866-889-8056. Peer-to-peer consultations for this program will be scheduled by eviCore in 15-minute increments. You will be notified of the time of your peer-to-peer discussion at the time the appointment is made.

Appeals

  • Our standard appeals process applies. Please refer to the Excellus BCBS Participating Provider Manual for further information.

Tracking Your Preauthorization

  • The ordering physician will be able to verify if a preauthorization request was approved by checking the status at www.evicore.com, or by calling eviCore Customer Service at 1-888-333-9036.
  • The preauthorization status function available at www.evicore.com will provide the following information:
    • Authorization number/case number
    • Status of request;
    • CPT code;
    • Procedure name;
    • Authorization date;
    • Expiration date (preauthorization is valid for 90 calendar days from the date of approval).
  • Once a preauthorization is finalized, if a patient requires different or additional services within the 90-day time frame, a new authorization number is needed.

Billing and Claims

  • Submit claims for authorized musculoskeletal services to Excellus BCBS.
  • As always, we reserve the right to conduct post service reviews for contracts that do not require preauthorization or for verification of clinical information submission.

Provider Education

  • In coming weeks, eviCore will lead orientation sessions designed to assist you and your staff with the new program. You will be able to attend the web orientation session that works best for your schedule. Complete information and registration instructions are available at https://www.evicore.com/healthplan/excellusbcbs
  • Also, tutorials are available at www.evicore.com that provide a general overview of the process for obtaining preauthorization through eviCore. These will be helpful to you if you do not currently obtain preauthorization for other services for our members through eviCore. To access the tutorials, go to: https://www.evicore.com/page/provider-overview-tutorials.aspx

Remember, as always, that failure to obtain preauthorization or to comply with your participation agreement or our member contract requirements, or UM policies and procedures, may result in a claim denial. 

We are mindful of the impacts to our providers as we strive to manage medical expenses to meet our responsibility to our members and employer group customers. We value the quality of care that you provide to our members and thank you for partnering with us in our effort to keep health care affordable.

Our goal is to ensure a smooth transition to the musculoskeletal preauthorization program. If you have questions, please contact your Provider Relations representative.

 
 
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