BlueCross and BlueShield of Montana Medical Policy/Codes
Prior Authorization
Chapter: Administrative
Current Effective Date: June 12, 2012
Original Effective Date: January 02, 2008
Publish Date: June 12, 2012
Revised Dates: March 7, 2012; April 30, 2012
Description

Prior authorization is a process Blue Cross and Blue Shield of Montana (BCBSMT) uses to make coverage decisions in accordance with medical policy and group/member contracts for a service, supplies, drugs, or devices (hereafter called services) used to diagnose or treat an illness or condition.

The Member is encouraged to obtain Prior Authorization from BCBSMT, to predetermine if a service is a covered benefit.  Prior Authorization is sometimes required and frequently recommended for proposed services, to help the member identify potential expenses, which the member may incur, if the services are found to be Non-Covered Expenses, or determined to be Not Medically Necessary or Investigational in nature. Just because Prior Authorization is not specifically recommended, does not mean the service or procedure is covered. Prior authorization approvals are only valid for specified time frames.  If BCBSMT approves a service during the prior authorization review, BCBSMT will not revoke that authorization unless:

The information submitted was materially erroneous or incomplete.

The approval has expired.

  • Evidence of material change in the Member's health condition between the date the prior authorization was provided and the date of the service make the proposed service no longer medically necessary.
  • The member is no longer insured by BCBSMT at the time the service is provided.
Policy

Services That BCBSMT Recommends Be Prior Authorized

Services with recommended prior authorization are listed in the Code Requiring Special Processing (CRDP) list www.bcbsmt.com(click on Providers, then Prior Authorization). If prior authorization has not been initiated and a claim has been received for services, a retrospective review is performed prior to claim adjudication. A retrospective review for a service that was not prior authorized delays claim processing, and may result in either the provider or member being responsible for all associated costs for the service.

If the member or provider is uncertain that the service will be covered, prior authorization is also recommended for services that are not included on the Codes Requiring Special Processing list. Clarification may be needed for one or more reasons including, but not limited to, the following: 

  • Treatment for a specific condition is excluded in the member contract. These exclusions can be pre-existing conditions and/or contract limitations 
  • The service may be determined to be experimental/investigational or may be excluded in the member contract. Many of these services are listed in the medical policy Experimental/Investigational Services. Some services may not be listed within the policy and still be determined to be experimental/investigational because:
    • The service is new and the safety, effectiveness and/or appropriate utilization are unknown.
    • The service may not have a CPT code and is correctly billed using an unlisted code. While BCBSMT attempts to keep the experimental/investigational code list complete, we can not guarantee that every service represented by an unlisted code is represented.
  • BCBSMT may determine a service to be not medically necessary. Refer to the medical policy Medically Necessary Services for more information.
  • When records are needed to clarify the nature of the service (such as an unlisted code).
  • For specific durable medical equipment (DME). BCBSMT member contracts limit purchase or rental to the most appropriate type of equipment, when medically necessary. Most group or member contracts recommend prior authorization. Refer to the specific member contract and medical policies that reference DME for more information.

Related Services

If prior authorization is denied, charges for all other associated services are also denied as non-covered services. BCBSMT member contracts exclude coverage for “services or supplies for the treatment of illness, injury and/or complications resulting from services that are not covered medical expenses.” This contract exclusion applies to services that have been denied through prior authorization because the services are considered “not covered medical expenses.”

Related services can include, but are not limited to, the following:

  • Hospitalization
  • Operating room
  • Anesthesia
  • X-ray
  • Laboratory
  • Pathology
  • Supplies
  • Rehabilitation
  • Office and outpatient visits
  • Physician or other provider services
  • Medications

Services That BCBSMT Requires Be Prior Authorized

RADIATION ONCOLOGY

Prior authorization for radiation therapy services is required for members and providers who are eligible for the CareCore Program.  Members and providers anticipating the need for radiation therapy services covered by BCVBSMT are encouraged to either contact BCBSMT customer Service Department at 1-800-447-7828, or CareCore National at 1-866-668-7446, or httr://www.carecorenational.com/ to determine program eligibility and confirm coverage determinations.  Benefits for services provided to members eligible for the CareCore Program that have not been prior authorized will be denied.

Participating Providers are REQUIRED to Prior authorize Radiation Oncology Therapy for Blue Cross Blue Shield of Montana (BCBSMT) Members eligible for the CareCore Program*. To authorize, Utilize CareCore National’s website: http://www.carecorenational.com/  or call 1-866-668-7446, option1. Services that are not prior authorized will be denied. For benefit questions call (BCBSMT) Customer Service at 1-800-447-7828.

CPT codes that require prior authorization through CareCore National:

0330, 0333, 0339, 0344, 0973, 0073T, 0182T, 0190T, 0197T, 17999, 19296, 19297, 19298, 31627, 31643, 32553, 41019, 43241, 49411, 55875, 55876, 55920, 57155, 57156, 58346, 58999, 76873, 76950, 76965, 77011, 77014, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77299, 77300, 77301, 77305, 77310, 77315, 77321, 77326, 77327, 77328, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77371, 77372, 77373, 77399, 77401, 77402, 77403, 77404 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418, 77421, 77422, 77423, 77427, 77431, 77432, 77435, 77470, 77499, 77520, 77522, 77523, 77525, 77600, 77605, 77610, 77615, 77620, 77750 ,77761, 77762, 77763, 77776, 77777, 77778, 77785, 77786, 77787, 77789, 77790, 77799, A4648, A4650, C1715, C1716, C1717, C1719, C1728, C1879, C2616, C2634, C2635, C2636, C2637, C2638, C2639, C2640, C2641, C2642, C2643, C2698, C2699, C9725, C9726, C9728, G0173, G0251, G0339, G0340, Q3001, S8030

NOTE: This applies to all fully insured and self insured lines of business except the following:

  • *These Policies are not eligible for the CareCore Program:

State of Montana, Department of Corrections, Student Athletes, Medicare Supplements, FEP, Blue Card HOST, HMK 

How To Prior Authorize A Service

 A provider or member may initiate a prior authorization by calling the BCBSMT Customer Service Department at 1-800-447-7828 or fax your request to the Medical Review Department at 406-441-4624. A retrospective review may be performed if services are not prior authorized.

Rationale for Benefit Administration
This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. Blue Cross and Blue Shield of Montana
recognize the rapidly changing nature of technological development and welcome provider feedback on all medical policies.

When using this policy to determine whether a service, supply, drug or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.
History
March 2012  Prior authorization statement changed to required for Radiation Therapy Service. Updated statement to reflect phone number and website Radiation Therapy Services are submitted through.
April 2012 Added non-participating self insured groups to policy
June 2012 Policy statement re-arranged on recommendations from the Medical Director. No other changes made.
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CPT codes, descriptions and material only are copyrighted by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. CPT only © American Medical Association.
Prior Authorization