New prior authorization requirements begin this summer

This summer, Blue Cross Blue Shield of Michigan Medicare Advantage will start a new prior authorization program. Services that will require prior authorization include:

• Select specialty medications 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. This program will begin July 5, 2017.
• Select surgical procedures. This program will begin July 31, 2017.

Doctors 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 rejected. At that time, a doctor may still submit a request and obtain authorization within 120 days of the date of service, even though the patient has already received the services. However, the patient must meet all of the 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.

Blue Cross is creating this utilization management program to respond to concerns from many of our major group customers about potential safety issues and appropriate utilization of these services. A few of the services included in the program are listed at the end of the article. A complete code listing subject to the new requirement will be available on the Blue Cross provider site before the program launches.

On an ongoing basis, we’ll evaluate the program and may add or remove new drugs or procedures from the prior authorization list. When this happens, we’ll notify you.

Providers will submit authorization requests for these services electronically. 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.

Part B drug requests should be submitted starting July 5, 2017, through NovoLogix^®, a secure online tool. 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.

Surgical procedure requests should be submitted through e-referral beginning July 31, 2017. Providers should be accustomed to using this system for their Blue Care Network members.

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

Below is a sampling of specialty drugs that require Medicare Part B prior authorization.

The following is a sampling of surgical procedures that require prior authorization:

• Arthroplasty (hip, knee, shoulder)
• Correction of hammertoe
• Nasal/sinus endoscopy
• Endovascular intervention, peripheral artery
• Radiofrequency ablation and TACE, Liver
• Vagus nerve stimulation
• Intrathecal catheter/pump placement
• Spinal cord stimulator insertion