|
April 2023
Prior authorization changes coming in June
Michigan’s prior authorization law requirements** go into effect on June 1, 2023. These requirements apply to health care insurers and providers in Michigan for members who have commercial coverage.
These requirements aim to give members and health care providers a clearer understanding of the services that require prior authorization and of the prior authorization criteria for medical and pharmacy benefits.
The areas that will be affected are:
|
Area |
Requirements of the law |
Services and benefits that require prior authorization and medical necessity criteria |
The following must be posted to a publicly available website:
- A list of all services and benefits that require prior authorization
- Medical necessity criteria for all benefits
This information must be posted as follows:
- For medical services: 60 days in advance of changes
- For pharmacy services: 45 days in advance of changes, with some exceptions for patient safety
Note: While this information is currently available to Blue Cross Blue Shield of Michigan and Blue Care Network members and providers, we’re working to consolidate it, make it more easily accessible and present it in more easily understandable language.
The law also requires insurers to modify prior authorization requirements based on provider performance. We already have several gold carding programs in place that meet this requirement. |
Turnaround times |
Turnaround times for prior authorization requests will change.
- For standard prior authorization requests: We must make determinations on requests or ask for additional information as follows:
- Within 9 days of submission, for requests submitted on or after June 1, 2023
- Within 7 days of submission, for requests submitted on or after June 1, 2024
- For urgent*** prior authorization requests: We must make determinations on requests or ask for additional information within 72 hours of submission for requests submitted on or after June 1, 2023.
Note: If we ask for additional information, providers should submit it as soon as possible. Once the provider submits the additional information, the turnaround time noted above will reset. For example, we must make a determination within 72 hours of receiving additional information for an urgent request.
Approved prior authorization requests will be valid for a minimum of 60 days or for the length of time that’s clinically appropriate, whichever is longer.
As is true now, providers and members will be able to appeal prior authorization requests that aren’t approved. |
Electronic prior authorizations |
Insurers must provide an online method through which providers can submit prior authorization requests for all services, including prescription drugs. Online submission methods include our e‑referral tool, online tools provided by vendors who manage certain authorizations on our behalf and electronic prior authorization, or ePA, tools.
Notes:
- We’ll continue to provide alternate submission methods (fax or phone) for times when providers are unable to submit requests online due to power outages, internet outages and so on.
- For members who have Blue Cross commercial coverage through MESSA, providers must submit prior authorization requests to MESSA for certain services. Starting June 1, there will be a new process for providers to submit these requests online for MESSA members. Look for additional information in upcoming provider alerts and issues of The Record.
|
Reporting |
Insurers must submit reports about prior authorizations annually to the Michigan Department of Insurance and Financial Services, or DIFS, on June 1 of each year, beginning in 2023.
Reporting will include the number of prior authorization requests that weren’t submitted to us using an online submission method. |
Member appeals |
We’ll communicate details before June 1. |
These requirements also apply to the third-party vendors with which Blue Cross and BCN have contracted to manage prior authorizations for certain services. We’re working with these vendors to ensure compliance with the law.
As we make changes, we’ll publish provider alerts and newsletter articles with additional information. For example, we announced in the February issue of The Record that voluntary prior authorization ends on May 1.
Be sure to check member eligibility and benefits through our provider portal (availity.com)** or Provider Inquiry prior to performing services.
Availity is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
***A request for medical care or services is considered urgent when the time frame for making determinations for routine or non-life-threatening care would do one of the following:
- Seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a layperson’s judgment.
- Seriously jeopardize the life, health or safety of others, due to the member’s psychological state.
- Subject the member to adverse health consequences without the care or treatment that is the subject of the request, in the opinion of a practitioner who has knowledge of the member’s medical or behavioral condition.
|
