Government Programs Pre- Authorization / Pre-Certification

Transcription

1 BlueCross BlueShield of Minnesota Government Programs (Blue Plus Secure Blue (MA-SNP) and Blue Plus Blue Advantage (PMAP, MNCare, and MSC+)) Pre- Authorization / Pre-Certification Overview BlueCross BlueShield of Minnesota (BCBSMN) has a pre certification 1 process for various services, procedures, prescription drugs, and medical devices. The full list of services, procedures, prescription drugs, and medical devices 2 that require pre certification can be found at the end of this document. The pre certification process determines whether medical necessity exists based on clinical criteria and is not a reflection of a member s benefits or eligibility. Benefits and eligibility must be verified each time a member seeks services. Submitting Pre Authorizations 3 / Pre Certifications / Notifications Providers may submit pre authorization / pre certification requests to BCBSMN Utilization Management Department using the appropriate form: Government Programs Pre Authorization / Pre Certification Form When submitting a pre authorization / pre certification request, please ensure the following are available: The patient name (as it appears on the member s identification card) The patient subscriber ID and group number The patient date of birth The patient demographic information Name of servicing physician and NPI number Name of ordering physician and NPI number Diagnosis/CPT/HCPCS codes pertinent to the requested service Narrative description of service requested Clinical documentation to support the service request Requestors contact name, phone and fax number and location To assure timely processing, please fax your request to the published number on the PA form. 1 Pre-certification refers to the process of reviewing selected, non-emergency procedures/services for medical necessity prior to the member (patient) receiving the procedure/service 2 Services, procedures, prescription drugs and medical devices may be referred to as simply service(s) in the remainder of this document 3 Prior authorization is a process that involves a benefits review and determination of medical necessity before a service is rendered. Page 1

2 Note: Members who are dual eligible for Medicare and Medicaid are subject to review utilizing Medicare guidelines first if applicable, and then the guideline listed below. Inpatient, Allied, and Behavioral reviews are subject to McKesson criteria. McKesson criteria are available upon request. MN Health Care Provider Manual () or Community Based Services Manual (CBSM) are Department of Human Services Criteria for Medicaid members. These criteria are available through the web link provided. Pre Authorization / Pre Certification List If a question arises regarding a specific service, please contact Provider Services at: or (651) to verify if pre authorization / pre certification is required. The below list is not all inclusive and is meant as a guideline only. All services are subject to the member's benefits and medical necessity guidelines. Blue Plus may request a medical necessity review of a service even if a pre certification/preauthorization is not required. Guidelines applied are based upon the member's product. Blue Cross Blue Shield of Minnesota Government Programs Notifications Acute Medical and Behavioral Inpatient All admissions require Pre Admission Notification (PAN) Notifications: o Notification of mental health and chemical dependency residential admissions is required. Pre Admission Notification Definition: When a patient is admitted to a facility as an inpatient, the admitting office or admitting physician notifies BCBSMN of the admission. This is a notification only and does not require medical necessity criteria review to be completed at the time of admission. Criteria used Blue Cross Blue Shield of Minnesota Government Programs Pre Authorization / Pre Certification Service Category Ancillary Services Custom / / / Chiropractic Services: After 24 visits per calendar year Occupational Therapy: Out patient visits after 40 per calendar year Physical Therapy: Out patient visits after 40 per calendar year Speech Therapy: Out patient visits after 50 per calendar year Vision Therapy Behavioral Health Dimensions criteria Chemical Dependency Residential Admissions (MN providers) Page 2

3 X 26 Early Intensive Behavioral Intervention (EIBI) 9 hours/week or greater Eating Disorder Residential Services (MN providers) Mental Health Residential Admissions (MN providers) Quantitative Electroencephalography (QEEG) or Brain Mapping for Mental or Substance Related Disorders Durable Medical Equipment (DME) Amino Acid Based Formula (e.g. Elecare, Neocate) Bone Growth Stimulators Communication Devices Continuous Glucose Monitors Hospital Beds (All Types): Rental and Purchase Insulin Pump replacements Insulin Pumps Knee Microprocessor Scooters Seat Lift Mechanism Specialty Mattresses (Groups 2 and 3), except use for K0890, K0891 TENS Unit Ultraviolet Light Systems for Home Use Unlisted Codes over $250 (e.g. K0108, A6549, A9999, E1399) Vest Percussor Wheelchair in LTC Wheelchair Manual Wheelchair Repairs Wheelchairs, Power General Cosmetic Services Investigational / Experimental Services Page 3

4 Case By Case Review Non Urgent /Emergent Services by Non Par Providers Requesting Par Benefits High Tech Diagnostic Imaging Appendix A Breast MRI Capsule Endoscopy Coronary Artery MRI CT Colonography (Virtual CT) CTA of Coronary Arteries, including Coronary CT & EBCT for Calcium Scoring V 27 PET Scans Home Health Care/Therapies /CBSM /CBSM /CBSM /CBSM Extended Hours Home Care (Private Duty) Nursing Home Health Care (Skilled Nursing Visit & Home Health Aide) PMAP & MNCare Members: Home Care Visits: after 20 visits (Skilled Nursing and/or Home Health Aide) Secure Blue / MSC+ Members: Pre Certification/Pre Authorization not required for Medicare PPS Episodes. Home Care agencies should coordinate visits with the Member's Care Coordinator. All home care requests must come from the Care Coordinator. Hospice Care Hospital services for Billable Services (Medicare Hospice services require notification to the plan to assure proper benefit administration). No authorization needed for: Home OT/PT/RT/Speech/Language Therapy/Social Worker or Dietician in the home. PCA Services Inpatient Facility** Custom/Medicare Chapter 8 Acute Rehabilitation Admissions Non MN (other states) Admissions or Non Participating Facility Long Term Acute Care (LTAC) MSHO/Secure Blue Skilled Nursing Facility State of MN and bordering county providers (Medicare days only) Page 4

5 **Please note: Inpatient admissions included in the above grid require pre certification and the provider is required to contact BCBSMN as soon as the admission is scheduled, but no later than two working days after the admission occurs. Reviews of the submitted request will be completed in one business day. Inpatient services not included in the above grid do not require pre certification and require notification only. Pre Certification Definition: An advance notice of a proposed facility admission to determine whether the proposed admission meets the medical necessity criteria and to ensure that the member receives the maximum benefits available under the subscriber s plan. Pre Certification is based on a medical necessity review and is not a guarantee of payment. Payment requires that the contract is in force on the day services are provided and is subject to all provisions and limitations in the subscriber s contract including any applicable pre existing condition limitations, lifetime and benefit maximums, contract exclusions and health plan allowed amounts. Please contact provider services in regard to questions pertaining to member benefits: Blue Cross Blue Shield of Minnesota (BCSMN): or (651) (For internal transfer: x50354) Medications under the Medical Benefit II 107 II 143 II 144 II 162 II 51 Case By Case Review Case By Case Review II 74 Advanced Therapies for Pharmacological Treatment of Pulmonary Hypertension Ampyra Belimumab (Benlysta ) Botox Injections Cellular Immunotherapy for Prostate Cancer (Provenge ) Chelation Therapy Growth Hormone per BCBSMN, GenRx Formulary Omnitrope is the preferred medication H.P. Acthar Gel (Repository Corticotropin) Immunoglobulin IV or SQ Replacement Therapy Non FDA Approved Drugs Off label use of FDA Approved Drugs Transmucosal Fentanyl for Cancer Related Pain formulary exception request Progesterone Therapy (Makena hydroxyprogesterone caproate) Synagis Injections Page 5

6 II 29 Synvisc / Supartz / Hyaluronan Treatment of Hereditary Angioedema with C1 Inhibitor (Cinryze, Berinert) Procedures IV 24 II 33, II 46, except on Vertical Band (43842) use IV 14 Custom Custom VI 09 VI 48 IV 16 IV 86 IV 33 VII 25 Abdominoplasty Acne Treatment: Chemical Exfoliation & Cryotherapy Bariatric Surgery: all types including revisions BRCA Breast Implant Removal Breast Reduction Breast Reduction (Male) for Gynecomastia Circumcisions Dental Services Requested as a Medical Benefit Esophogastric Fundoplasty (e.g. Nissen) General Anesthesia for Dental Services Genetic Testing Genioplasty Hip Arthroplasty (Hip Replacement) ONLY when BOTH of the following criteria are met: 1. The member is enrolled in Minnesota Health Care Programs () of Blue Advantage Prepaid Medical Assistance Program (PMAP) and MinnesotaCare; AND 2. The member is under 60 years of age. Hysterectomy Implantable Ventricular Assist Systems & Artificial Hearts Knee Arthroscopic Knee Debridement only for members 45 years and older Mastopexy Orthognathic Surgery Panniculectomy Pelvic Floor Stimulator Page 6

7 II 39 for initial, for repeat for initial, for repeat IV 126 IV 26 Psoriasis Treatment (Also see DME) Radiofrequency Neuroablation for Facet Mediated (Back & Neck Pain) Joint Denervation Radiofrequency Neuroablation for Facet Mediated (Thoracic & Sacral Pain) Joint Denervation Rhinoplasty Routine Care Related to Clinical Trials Sacroiliac Joint Fusion Spinal Cord Stimulator permanent placement only Spinal Fusion (Cervical, Lumbar, & Thoracic) Subtalar Arthroereisis Surgical Treatment of Sleep Apnea (UPPP) Transplant All (excluding cornea & kidney) Vagus Nerve Stimulation Vein Treatment: Endoluminal Ablation Therapy, Spider Vein Treatment & Sclerotherapy Transplants Consult, evaluation workup & Human Leukocyte Antigen (HLA) typing and testing also called Tissue Typing, do not require a PA. Lung transplant, single: without cardiopulmonary bypass Lung transplant, single: with cardiopulmonary bypass Lung transplant, single: double (bilateral sequential or en bloc); without cardiopulmonary bypass Lung transplant, single: double (bilateral sequential or en bloc); with cardiopulmonary bypass Heart lung transplant with recipient cardiectomy, pneumonectomy Bone marrow transplant, allogenic Bone marrow transplant, autologous Bone marrow or blood derived peripheral stem cell transplantation; allogenic donor lymphocyte infusions Intestinal allotransplantation; from cadaver donor Intestinal allotransplantation; from living donor Page 7

8 BCBSA Liver allotransplantation; orthoptopic, partial or whole, from cadaver or living donor, any age Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells Transplantation of pancreatic allograft Donor lymphocyte infusion for malignancies treated with an allogeneic hematopoietic stem cell transplant Authorization is required for the following transplant procedures: stem cell (autologous, allogeneic, donor lymphocyte infusion), heart lung, lung, pancreas, pancreas kidney, liver, intestine liver, and autologous pancreatic islet cell transplant (after pancreatectomy). The medical report must include the following information: Diagnosis, including ICD diagnosis code Proposed treatment Sufficient, pertinent information Appendix A: Breast MRI As of September 1, 2008, authorization will be required for a breast MRI. will approve breast MRIs for screening and diagnosis when the criteria below are met. Scans that use intravenous MR contrast agents and specialized breast coils must be used in all cases. Approved indications are: Screening MRI of the breast is considered medically appropriate for screening women from 20 to 50 years of age on an annual basis if one of the following criterium is met indicating high risk: Previous diagnosis of breast cancer, including carcinoma in situ Presence of mutation in BRCA1 or BRCA2 Presence of another genetic syndrome linked to high risk of breast cancer Family history of breast cancer* consistent with the following criteria: Individuals with two or more first degree relatives or two or more first and second degree relatives (on the same side of the family with): o Breast cancer, diagnosed before age 50 years o Breast cancer, diagnosed before age 50 years in one or more relatives and ovarian cancer, diagnosed at any age in one or more relatives o Breast cancer, at least one of whom also had ovarian cancer, diagnosed at any age o Breast cancer, diagnosed at any age and Jewish ancestry o Male breast cancer, and a female diagnosed with breast cancer before age 50 or ovarian cancer History of exposure to heavy doses of ionizing radiation to chest, particularly during youth/adolescence Ovarian cancer, diagnosed at any age Previous diagnosis of atypical hyperplasia or neoplasia Page 8

9 Diagnostic MRI of the breast is considered medically appropriate for diagnostic evaluation of men/women of any age in the following clinical situations: Suspected occult primary tumor of the breast in a patient with axillary nodal adenocarcinoma, and negative physical exam and mammography Presurgical planning before and after neoadjuvant chemotherapy to permit tumor localization and characterization Presurgical planning for clinically localized breast cancer amenable to conservation therapy to evaluate the presence of multicentric disease Posteriorly located breast tumors to determine the extent of tumor invasion of the chest wall Page 9