Select procedures no longer need preauthorization

This is the first article in a series about procedures no longer needing Blue Cross Blue Shield of Michigan preauthorization.

After June 15, 2016, the following procedures that meet clinical criteria and are covered by the member’s benefits will no longer require preauthorization:

For the list of procedures above, we’ll return preauthorization requests and remind you to check the medical criteria to determine if a patient needs approval.

Cosmetic versus reconstructive surgery:

We define reconstructive surgery as a service that involves the restoration of a patient to his or her normal functional status. It can also be a service to repair a defect arising from illness, traumatic injury or surgery to return the patient’s appearance to its previous state.

Cosmetic surgery is a service performed solely to preserve or enhance appearance or self-esteem. It’s not considered medically necessary. For more information, check out this May 2015 Record article.

How to check web-DENIS for medical criteria:
Check the medical criteria to determine if a patient needs approval before you provide services. Here’s how:

1. Go to bcbsm.com and log in to Provider Secured Services.
2. Click on web-DENIS.
3. Click on BCBSM Provider Publications and Resources.
4. Click on Medical Policy and Pre-cert/Pre-Auth Router.
5. Click Medical Policies.
6. Insert search criteria in Keyword/Phrase and click Search.

Only request medical reviews when cases don’t meet criteria

By submitting the case for a medical review, you have identified the member does not meet criteria. Submit a copy of the patient’s relevant medical records with the letter requesting a medical consultant’s review. The letter should include the specific clinical findings or patient conditions that support medical necessity for the service and why special consideration is justified. We’ll give you our response within 15 days, which begins when we receive your letter along with the documentation for review.

To find routine benefit information
You may obtain benefit information, as well as medical policy and payment policy information, from Benefit Explainer online. To search for this benefit information on web-DENIS:

1. Open the web-DENIS tool.
2. Click Subscriber Info in the left navigation menu, then click Benefit Search. This link takes you to Explainer, our benefit research tool.
3. Click the BPR tab. (BPR stands for Benefit Package Report.)
4. Complete the required search criteria to view benefit policy rules that describe whether a code is payable for a group or member and any limitations that may apply.

To find policy and payment information
If you’re looking for our medical policy and payment policy information, you can find that while you’re already in Explainer:

1. Click the Medical/Payment Policy tab.
2. Complete the required search criteria to view Blue Cross’ general (not group-specific) medical and payment policy rules for a specific time frame.

To search for medical policy and payment policy information when you first log in to web-DENIS:

1. Click on BCBSM Provider Publications and Resources in the left navigation menu.
2. Click on Benefit Policy for a code. This link takes you directly to the Explainer, Medical/Payment Policy tab.

For patients in the groups listed below, call or write for approval of services.

**If criteria aren’t met, submit your request in writing to:

MESSA
1475 Kendale Blvd.
P.O. Box 2560
East Lansing, MI 48826-2560