Here’s some additional information about the Medicare Plus Blue^SM PPO prior authorization expansion

As you read in the July Record, 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, the purpose of prior authorization for these services and the effective dates.

Starting Sept. 1, 2016:

• Inpatient and outpatient lumbar spinal fusion surgery — Manage the utilization of spinal fusion surgeries to ensure clinical appropriateness
• Outpatient interventional pain management — Manage the use of outpatient interventional pain procedures, including epidural injections, facet block and radiofrequency ablations, to help eliminate inappropriate delivery of such procedures

Starting Nov. 1, 2016:

• Outpatient 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

EviCore healthcare will administer prior authorization for these services. EviCore is a national specialty benefit management company that focuses on managing quality and individual patients.

To request a prior authorization and to locate the clinical worksheets and CPT code list for the mentioned services:

• Access the eviCore implementation site: https://www.carecorenational.com/page/bcbsm-implementation.aspx, or
• Go to the Blue Cross website at www.bcbsm.com, click on Provider Secured Services, then log in to web-DENIS to find the authorization information.

The clinical worksheets will help guide you with the necessary information to request a prior authorization. The eviCore implementation site also includes Frequently Asked Questions, a Quick Reference Guide, national guidelines and information on webinars that will be available before the start date.

Although the recommended way and quickest way to obtain authorizations is online, you can call eviCore at 1-877-917-2583 (BLUE) to submit requests. If a prior authorization isn’t obtained for the above services, claims will be denied and providers will be responsible for the costs.

EviCore will be sending letters with a schedule of online orientation sessions to affected physician specialties.

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.