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July 2014
Preauthorization for proton beam therapy required
Effective July 1, 2014, Blue Cross Blue Shield of Michigan will require preauthorization for both in-state and out-of-state providers for proton beam therapy services. This will affect procedure codes *77520, *77522, *77523 and *77525 when reported with revenue code 0333.
The ordering physician must submit a preauthorization request before the treatment is provided and include the following information:
- Radiology report and rationale to support medical necessity
- Diagnosis codes
- Procedure codes
- Planned duration of treatment
For treatment plans effective July 1 through Aug. 30, 2014, please mail or fax preauthorization requests to:
Mail: |
Preauthorization, Provider Inquiry Services
Blue Cross Blue Shield of Michigan
P.O. Box 2227
Detroit, MI 48231-2227 |
Fax: |
1-866-311-9603
Attention: Preauthorization, Provider Inquiry Services |
For treatment that begins after Sept. 1, 2014, preauthorization requests must be made by calling American Imaging Management at 1-800-728-8008. AIM will review the requests and respond to BCBSM Provider Inquiry.
After a preauthorization request is received by BCBSM, the provider will receive a written response, detailing what the preauthorization approval includes, within approximately 15 days. The provider is required to follow the terms of the preauthorization as detailed in the written response.
This preauthorization process helps ensure that BCBSM criteria are met and, where appropriate, explains the proper use of alternative therapeutic modalities. To review the Charged-Particle (Proton or Helium Ion) Radiation Therapy Policy, click here.
Proton beam therapy, used for prostate cancer, hasn’t been demonstrated to be superior to other forms of external beam radiation therapy. The benefit and payment terms are limited to the allowed amount equivalent to intensity-modulated radiation therapy services. For contracted providers, this level of payment is considered payment in full and balance billing the member is not permitted.
Keep in mind that proton beam therapy must be provided in a facility and reported to BCBSM on a facility UB-04 claim. (Out-of-state providers can bill us on either a CMS-1500 or UB-04 claim form.)
Note: The preauthorization requirements described in this article do not apply to Chrysler, Ford, General Motors, Delphi, URMBT, State of Michigan or Federal Employee Program® members. Please refer to the medical policy to determine if medical necessity criteria have been met. | 