Return to Provider News

Preauthorization Updates Effective May 1, 2022 for All Lines of Business Requiring Preauthorization

Audience: All Providers

We would like to share updates regarding preauthorization under our Utilization Management (UM) Program.

The UM Program gives Excellus BlueCross BlueShield 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 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 where required, failure to comply with your provider agreement, or our member contract requirements may result in claim denial or reduction in payment.

For details on preauthorization updates effective May 1, 2022, please refer to the singular PDF document. This singular document replaces the individual documents previously posted for medical, durable medical equipment, eviCore and behavioral health preauthorization guidance.

Each preauthorization update effective May 1, 2022 will be highlighted in gray.

Courtesy Preauthorization

>Courtesy preauthorization continues to be available, at our discretion, for select services and product lines.

InterQual® Updates

We will update InterQual information on our website when it becomes available. You will receive advance written notice regarding the effective date of any InterQual updates or revisions.

Medical Necessity Audits

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 2022 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.

Durable Medical Equipment (DME)

Claims will deny or suspend for medical necessity review across all lines of business if preauthorization for applicable DME is not obtained. View the current list of DME requiring preauthorization.

Medicare Line of Business

We follow the CMS coverage guidelines for our Medicare Advantage line of business. These policies are located at MCD Search (cms.gov)

In accordance with CMS guidelines, our Medicare Advantage members are required to use Medicare-approved facilities for select services. Refer to www.cms.hhs.gov/MedicareApprovedFacilitie/01_Overview.asp. To view the list of approved facilities for these procedures, visit https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Non-Emergency-Medical-Transport.

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

Related News
UPDATE – Preauthorization Requirements for Select Cardiology Services

Preauthorization Updates Effective October 1, 2022, for All Lines of Business Requiring Preauthorization

Drug-Eluting Sinus Stents for Post-operative use following Endoscopic Sinus Surgery Medical Policy Update Effective September 15, 2022

Musculoskeletal Medical Policy Updates Effective September 15, 2022

Category

Excellus

Utilization Management

IE Browser Modal