The Record - We're making some changes to our prior authorization processes

We’re making some changes to our prior authorization processes

As you read in the April 2017 Record, there are three major changes coming to our prior authorization processes as follows:

Beginning July 5, we’ll require prior authorization for our Medicare Advantage PPO patients for select specialty medications covered under the Medicare medical benefit. (These are medications that aren’t self-administered but must be administered via injection or infusion in a physician’s office by a doctor or health care professional.)

Beginning July 31, 2017, prior authorization for Medicare Advantage patients will be required for select surgical procedures. Procedures will include the following:

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

Beginning July 31, 2017, we’re moving from the prenotification system to e-referral. If you’ve been using the prenote system for services requiring prior authorization (also called authorization or preauthorization), you’ll be switching to e-referral.

Note: If you’re not an e-referral user already, you can sign up on the Sign up for e-referral or change a user page on the ereferrals.bcbsm.com website. The page contains information providers need to sign up for access to the e-referral system.

The table below outlines all the prior authorization programs for Medicare Advantage PPO and commercial members, including the changes that are coming in July:

Service	Line of business	Current process	New process
Prenotification – inpatient acute admissions	MA PPO Commercial	web-DENIS	e-referral (July 31, 2017)
Concurrent review — inpatient acute admission	MA PPO Commercial	Only commercial URMBT — faxed review	e-referral (July 31, 2017)
Post-acute care authorization (skilled nursing facility, long-term acute care hospital, rehabilitation facility)	MA PPO	In-state — eviCore Outstate — fax or phone	No change
Post-acute care authorization (skilled nursing facility, long-term acute care hospital, rehabilitation facility)	Commercial	Fax or phone	No change
Transplant	Commercial	Fax or phone	e-referral (July 31, 2017) or fax/phone
Prior authorization (Select medical/surgical codes)	MA PPO	There are no current prior authorization requirements.	e-referral (July 31, 2017)
Prior authorization (Select Part B drugs)	MA PPO	There are no current prior authorization requirements.	NovoLogix^® (July 5, 2017)
Prior authorization (Drugs paid under medical benefits)	Commercial	NovoLogix	No change
High-tech radiology or echocardiology; proton beam therapy	MA PPO Commercial	AIM	No change
Sleep studies	Commercial	AIM	No change
Mental health (inpatient, partial hospital and intensive outpatient)	MA PPO	Phone	e-referral (Q4 2017)
Mental health (inpatient, partial hospitalization and intensive outpatient)	Commercial	New Directions (or group-specific vendor)	No change
Radiation therapy	MA PPO	eviCore	No change
Interventional pain management	MA PPO	eviCore	No change
Spinal surgery	MA PPO	eviCore	No change
Physical therapy or occupational therapy	MA PPO	eviCore	No change
NOC codes, experimental, potentially cosmetic procedures, off-label drugs, genetic testing, gender reassignment and Optune^® device	Commercial	Fax or mail	No change

More information

For information on a webinar on Blue Cross’ Medicare Plus Blue^SM PPO medical drug authorizations, see the article in this issue.

We’ll provide details on how you can get trained on e-referral in the July issue of The Record.