Return to Provider News

Medical Utilization Management Updates

Audience: All Providers, Facilities, Hospitals

We would like to share an overview with you regarding our standard medical Utilization Management (UM) Program updates coming soon. 

Breast reconstruction, including implant insertion, removal or reinsertion continues to require pre-authorization unless the member has a diagnosis of breast cancer. Breast reconstruction due to a breast cancer diagnosis does not require preauthorization. We are updating our diagnosis code list effective for requests beginning August 1, 2020, to include the most current ICD-10 codes for which preauthorization of breast reconstruction is not required due to a breast cancer diagnosis. Updates will be posted to on July 17, 2020. Updates apply to all lines of business.

Additional UM Program updates will be effective for requests beginning October 15, 2020. These updates will be posted to September 15, 2020. Specific updates apply to the products as noted on the reverse of this notice. 

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.

Preauthorization will be removed for these codes as of August 1, 2020:  

Commercial and Medicare Advantage HMO/PPO
50380, E0562

Safety Net (HMOBlue Option, Blue Choice Option, Premier Option, Blue Option Plus, Premier Option Plus, Child Health Plus, Premier Child Health Plus, and the Essential Plan)

Preauthorization will be added October 15, 2020, for the following codes for the Essential Plan. These services currently require preauthorization for all other Safety Net programs.

11920, 19355, 19357, 19499, 43999, 50590, 64581, 69930, C1767, C1820, E0199, L8600, V5140, V5257, V5258, V5261

Preauthorization will be added October 15, 2020, for the following codes for HMOBlue Option, Blue Choice Option, Premier Option, Blue Option Plus, Premier Option Plus, Child Health Plus, and Premier Child Health Plus (Note: These services currently require preauthorization for the Essential Plan)

20527, 31295, 67999, C1726

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.

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 at

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

In accordance with CMS guidelines, our members with Medicare coverage are required to use Medicare-approved facilities for select services. Refer to

A list of the approved facilities for these procedures are at

Related News
Updated Administrative Policy 32—Billing and Reimbursement Guidelines for Increased Procedural Services Effective July 21, 2020

CareAdvance Provider® Reminders

Billing Requirements for Administrative Policy AP-26 – COVID-19 Viral and Antibody Testing; Reimbursement Information

AP-34 Optometry Scope of Practice Administrative Policy Effective October 1, 2020

Reminder: Refund Request Notification Process




Policies & Clinical Criteria

Utilization Management