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Medical Utilization Management Program Updates Effective July 1, 2019

We would like to share an overview with you regarding our standard medical Utilization Management (UM) Program updates effective for requests beginning July 1, 2019. These updates will be posted to our website, ExcellusBCBS.com, June 3, 2019.

The UM Program gives the health plan and its health care provider partners the opportunity to monitor medical episodes of care to prevent unnecessary treatment and duplication of services. The UM program manages a subset of select services to ensure medically necessary care is being provided.

Preauthorization is required for all services listed on our preauthorization list for member contracts requiring preauthorization, regardless of the place of service (i.e., office, inpatient or outpatient setting). Please keep in mind that failure to follow UM policies and procedures, including failure to obtain preauthorization, failure to comply with your provider agreement or our member contract requirements may result in claim denial or reduction in payment.

Thank you for your continued partnership in the care of our members.

 

Commercial and Medicare Preauthorization Requirements

The following Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes will be added to our preauthorization list for our Commercial and Medicare lines of business for dates of service effective July 1, 2019, and require preauthorization if required under the member’s contract:

0037U, 0404T, 36473, 36474, 36482, 36483, 37241, 81545, 81541, 81551, 88120, 88121, 91110, 93228, 93229, E0691, E0692, E0693, E0694, 48160, G0341, G0342, G0343

As in previous updates, we will add CPT and HCPCS codes for services already on our preauthorization list. Newly added codes will be shaded in gray on the updated preauthorization list posted to the website.

The following individual codes will be removed for services already included in the list for our Commercial and Medicare lines of business:

32998, 47135, 47143, 47144, 47145, 47146, 47147, 43631, 77082, 83987, G0295, S8040, 81350

Safety Net Preauthorization Requirements

The following HCPCS/CPT codes will be added to our preauthorization list for our safety net products (Child Health Plus, Premier Child Health Plus, HMOBlue Option, Blue Choice Option, Premier Option, Blue Option Plus, Premier Option Plus) effective July 1, 2019, and require preauthorization if required under the member’s contract:

0037U, 0404T, 36473, 36474, 36482, 36483, 37241, 43284, 43285, 58674, 81541, 81545, 81551, 88120, 88121, E0691, E0692, E0693, E0694, G0341, G0342, G0343, 91110, 91111

As in previous updates, CPT and HCPCS codes will be added for services already on our preauthorization list. Newly added codes will be shaded in gray on the updated preauthorization list.

The following individual codes will be removed for services already included in the list for safety net products:

47135, 47143, 47144, 47145, 47146, 47147, 43631, 81350, 83987, G0295, S8040

Courtesy Preauthorization

Courtesy preauthorization continues to be available for member contracts that do not include a preauthorization requirement, at our discretion, for select services and product lines.

InterQual® Updates

We will update InterQual information on our website when it becomes available. Any updates or revisions will be communicated to you when InterQual releases its revisions.

Medical Necessity Audits

All medical services provided to our members are subject to medical necessity requirements. As we update our UM programs, we will implement additional retrospective reviews as needed using medical necessity post-service reviews or medical necessity audit(s), in lieu of preauthorization. Please be aware that these audits or reviews may be conducted post-service pre-payment and/or post-payment. As part of the UM retrospective review program, we will implement select medical necessity audits throughout 2019 and will provide notice of any additional details.

We are mindful of the impacts to our providers as we strive to manage medical expense to meet our responsibility to our members and employer groups.

Medical Specialty Drugs

Claims will deny or suspend for medical necessity review across all lines of business if preauthorization for medical specialty drugs is not obtained. An updated list of our medical specialty drugs requiring preauthorization is accessible via our website, Provider.ExcellusBCBS.com. Please visit our website frequently for updates to this list. New drugs are added to the list as they receive U.S. Food and Drug Administration approval throughout the year.

Behavioral Health

Claims will deny or suspend for medical necessity review across all lines of business if preauthorization is not obtained. An updated list of Behavioral Health services requiring preauthorization is accessible via our website, Provider.ExcellusBCBS.com.

eviCore healthcare

The Health Plan has contracted with eviCore healthcare, an independent company, to manage preauthorization for some services. Claims will deny or suspend for medical necessity review across all lines of business if preauthorization is not obtained through eviCore healthcare for services which it manages. An updated list of services managed by eviCore which require preauthorization is accessible via our website, Provider.ExcellusBCBS.com.

Durable Medical Equipment (DME)

Claims will deny or suspend for medical necessity review across all lines of business if preauthorization for Durable Medical Equipment is not obtained. An updated list of durable medical equipment requiring preauthorization is accessible via our website, Provider.ExcellusBCBS.com.

Medicare Line of Business

We follow the Centers for Medicare & Medicaid Services coverage guidelines for our Medicare line of business. These policies are located at https://www.cms.gov/medicarecoverage-database/overview-and-quick-search.aspx.

In accordance with CMS guidelines, our members with Medicare coverage are required to use Medicare-approved facilities for select services. A list of the approved facilities for these procedures are at www.cms.hhs.gov/MedicareApprovedFacilitie/01_Overview.asp.

Also, in accordance with CMS guidelines, our members are required to use Medicareapproved transplant centers for certain transplant services.

A list of Medicare-approved facilities is available on the CMS website at: www.cms.gov/Medicare/ProviderEnrollmentandCertification/CertificationandComplianc/Downloads/ApprovedT ransplantPrograms.pdf

 
 
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