Audience: all providers
We would like to share updates with you 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 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 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 to be effective May 1, 2021, please refer to the following documents:
- Medical Preauthorization Code List – May 1, 2021
- DME Preauthorization List – May 1, 2021
- eviCore Codes Requiring a Preauthorization – May 1, 2021
Each preauthorization update effective May 1 will be highlighted in gray.
Care Advance Provider® System Changes for Essential Plan Only:
Our Essential Plan membership now aligns with our Safety Net line of business; therefore, we are changing the CareAdvance Provider tool to align with the other products in our Safety Net line.
Also, effective May 1, 2021, Excellus BlueCross BlueShield will require that all preauthorization requests entered in our CareAdvance Provider tool for Essential Plan members will pend for a utilization review by our medical team. Therefore, these requests will not produce an automatic approval if all criteria are met.
The following HCPC codes and CPT codes will be impacted:
A9276 E0784 K0009
A9277 E1161 K0553
A9278 E1233 K0554
E0470 E1234 95782
E0471 E1236 95783
E0561 E1237 95805
E0601 E1280 95808
E0720 K0005 95810
Courtesy preauthorization continues to be available, at our discretion, for select services and product lines.
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 2021 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 Durable Medical Equipment is not obtained. The current list of Durable Medical Equipment requiring preauthorization is accessible here.
Medicare Line of Business
We follow the CMS coverage guidelines for our Medicare Advantage line of business. These policies are located at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.
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.
A list of the approved facilities for these procedures is at https://www.cms.gov/Medicare/Transplantation/01_overview.
Thank you for your continued partnership in the care of our members.