Outpatient facilities added to Medicare Plus Blue prior authorization program

Beginning June 28, 2018, Blue Cross Blue Shield of Michigan expanded its prior authorization program for Medicare Plus Blue^SM PPO specialty medical medications that are billed on a professional claim form to include outpatient facilities, place of service 19, 22 and 24. Currently, only place of service 11 is part of this program.

What you need to know

• Select specialty medications are covered under the Medicare Part B medical benefit. The selected medications are not self-administered and must be administered (via injection or infusion) by a doctor or health care professional. In addition to current place of service 11, expansion to include outpatient facilities with place of service 19, 22 and 24 will begin June 28, 2018.
• Place of service definitions:
• 11 – Provider office
• 19 – Off-campus outpatient hospital
• 22 – On-campus outpatient hospital
• 24 – Ambulatory surgical center
• Prior authorization is required for professional claims submitted on an HCFA 1500 form or ANSI 837P electronic submission with place of service 11, 19, 22 and 24. Facility claims submitted using UB claim submission aren’t in scope for this expansion.
• Providers must obtain prior authorization and verify patient benefits to be eligible for payment for administering these services. If a prior authorization isn’t obtained before services are rendered, the claim will be denied for no authorization on file. At that time, a provider may submit a retroactive authorization request within 90 days of the date of service. Patient must meet all requirements and have the necessary coverage for the claim to be payable.
• Authorization isn’t a guarantee of payment. Benefits and eligibility must be determined at the time services are rendered.

Providers will submit Part B medical drug requests for dates of service electronically through NovoLogix^®, a secure online tool, on or after June 28, 2018. NovoLogix allows providers to obtain real-time status checks on prior authorizations and to obtain immediate approvals for certain medications when patients meet the criteria. Submitting these requests electronically is the preferred method because it saves time and allows you to view the status of the request at any time. If your patient has an existing prior authorization for a provider-administered drug on file, an additional authorization for place of service 19, 22 or 24 isn’t required.

Future notifications will be sent that will provide you with the date when you can begin entering cases through the medical prior authorization e-tool if the patient doesn’t have an existing prior authorization on file with the provider’s office.

Look for more information about NovoLogix training and other program details in future issues of The Record and on web-DENIS.