Medicare Plus Blue^SM PPO prior authorization program to continue its expansion

Blue Cross Blue Shield of Michigan will expand its prior authorization program later this year to include three additional types of services for our Medicare Plus Blue^SM PPO members who reside in Michigan and use Michigan providers.

The expansion is intended to eliminate the unnecessary use of certain procedures to improve patient care and manage health care costs. Following are the three additional types of services that will require prior authorization:

• Lumbar spinal fusion surgery — Manage the utilization of spinal fusion surgeries to ensure clinical appropriateness.
• Interventional pain management — Manage the use of interventional pain procedures, including epidural injections, facet block and radiofrequency ablations, to help eliminate inappropriate delivery of such procedures.
• Radiation oncology — Manage the use of radiation therapy inclusive of modalities, dosing, coding and treatment goals, while reducing expenditures and the patient’s exposure to radiation therapy.

Prior authorization for these services will be administered by eviCore healthcare. EviCore is a national specialty benefit management company that focuses on managing quality and use for individual patients.

Providers will need to contact eviCore to request prior authorization for these services. If a prior authorization isn’t obtained for the above-mentioned services, claims will be denied as provider-liable.

For more information on changes to the post-acute care prior authorization process, read Reminder: Medicare Plus Blue^SM post-acute care prior authorization process changing June 1 in the June Record.

We’ll provide more details about these changes in future issues of The Record. We’ll also announce opportunities for training on the prior authorization expansion through web-DENIS broadcast messages.