Here’s more information about new preauthorization program for commercial PPO

As we communicated in the October Record article titled “Preauthorization program for commercial Blue Cross PPO plans coming in January,” some of our commercial PPO members will require preauthorization for the services listed below, beginning Jan. 1, 2018. The requirement is for our members with individual health plans and some of our members with coverage through their employers.

• Interventional pain management
• Radiation therapy (oncology) services
• Inpatient and outpatient lumbar spinal fusion surgery

The prior authorization program for these members will be administered by eviCore healthcare, a national specialty benefits management company that focuses on quality, cost and use of health care services.

To view a list of codes, visit the eviCore site.

How to determine if a prior authorization is required for your patient
If you schedule a patient for a procedure that is from one of the three programs then you:

• Log in to Provider Secured Services and go to web-DENIS.
• Under Subscriber Info on the left-side of the page, click Eligibility/Coverage.
• Select Prior Authorization.
• Once you verify that prior authorization is required, contact eviCore for a prior authorization request through one of the following:
• eviCore’s online portal through web-DENIS
• By phone at 1-877-917-2583, from 7 a.m. to 8 p.m. Monday through Friday

You’ll need to provide eviCore with the following information for the prior authorization request:

• Member ID, name and date of birth
• Rendering facility name and address
• Referring or ordering physician name, NPI, state and ZIP code
• Patient treatment plan, clinical presentation
• Completed physician worksheet
• Supporting information such as imaging studies, prior tests and related office notes

Authorizations submitted online are typically processed within three calendar days. In most cases, authorizations are processed on the same day. For expedited authorizations, call 1-877-917-2583.

You can request prior authorization through eviCore beginning Dec. 18 for services on or after Jan. 1, 2018.

What happens next

Approved requests are faxed to the ordering provider, mailed to the member or printed on demand at eviCore website. Authorizations are good for 45 calendar days from the date of determination for interventional pain management and lumbar spinal fusion. For radiation therapy (oncology), the number of days the authorization is valid varies based on the procedure.

Denied requests are communicated, along with determination and rationale, via fax to the ordering provider and mailed to the member. Appeals and peer-to-peer conversation requests can be sent to eviCore. This information will be available at the eviCore website in December.

Liability
If a member sees an in-state participating provider and services are rendered before prior authorization is obtained, the provider is held liable. If a member sees an in-state non-participating provider or an out-of-state provider and prior authorization is not obtained before services are rendered, the member is held liable.

Training
To help you make a smooth transition, we’re offering online training on the prior authorization process through eviCore.

Training sessions will cover:

• Overview of eviCore healthcare
• Overview of eviCore’s clinical approach
• Review of prior authorization process and specifics of the program
• Review of web portal
• Overview of eviCore’s provider resources

Online training dates

Each session is 60 minutes. The training will be recorded and then available on web-DENIS.

How to register for a training

• Select a date and time for the program you’re interested in.
• Go to evicore.webex.com.
• Click on the Training Center tab at the top of the page.
• Click the Upcoming tab and find the date and time of the conference you wish to attend.
• Click Register and enter the registration information.

Note: The sessions are named “Blue Cross and Blue Shield of Michigan Radiation Therapy Provider Orientation” and “Blue Cross and Blue Shield of Michigan Interventional Pain & Lumbar Spine Fusion Provider Orientation.”

After you have successfully registered for the conference, you’ll receive an email containing the toll-free phone number and meeting number, conference password and a link to the web portion of the conference. Please keep the registration email so you’ll have the information for your session.

Training sessions will be stored at the eviCore site and can be accessed for future reference.

How to contact eviCore

Email ClientServices@eviCore.com or call 1-877-917-2583, from 7 a.m. to 8 p.m. Monday through Friday, for issues that require immediate attention such as:

• Provider verification
• Authorization questions
• Letter issues
• Member eligibility issues
• eviCore healthcare standard processes and procedures
• Data questions or issues

Note: MESSA is currently excluded. Auto groups and the UAW Retiree Medical Benefits Trust are also excluded. Blue Care Network HMO isn’t affected by this change.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.