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 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.
Please be aware that ancillary services provided in conjunction with the eviCore Radiation Therapy Program will no longer require preauthorization for any line of business. Your preauthorization request process through eviCore for radiation therapy services will not change.
For details on preauthorization updates effective August 1, 2021, please refer to the following documents by clicking here
- Medical Preauthorization Code List – August 1, 2021
- DME Preauthorization List – August 1, 2021
- eviCore Codes Requiring Preauthorization – August 1, 2021
Each preauthorization update effective August 1 will be highlighted in gray.
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 DME is not obtained. The current list of DME 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 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.Email this article