Notice Of Change To Preservice Appeals Process For Medicare Patients

Jul. 19, 2019

There are important changes to the preservice appeals process for Blue Cross and Blue Shield of Montana (BCBSMT) patients enrolled in Medicare programs.

Beginning November 1, 2019, eviCore ® healthcare (eviCore), an independent medical benefits management company, will no longer administer the appeals process for denied and partially denied Medicare Advantage prior authorization requests. BCBSMT will assume responsibility for conducting the preservice appeals process, from preservice appeal intake to appeal determination. eviCore will, however, continue its role in administering the initial determination of prior authorization requests.

Note: The medical policies being used for these preservice appeal reviews will not change. Remember when submitting a pre–service appeal always follow the directions included within the denial letter.

These changes will streamline workflows and lead to an improved member and provider experience.

Going forward, it is critical to use Availity® or your preferred vendor to check eligibility and benefits, determine if you are in–network for your patient and whether any preauthorization or prenotification is required. Availity allows you to determine if preauthorization is required based on the procedure code. Refer to “Eligibility and Benefits” on the provider website for more information on Availity. Providers can also refer to the Preauthorizations page on the provider website.

For other services requiring preauthorization through BCBSMT, use iExchange® to preauthorize those services. For more information or to set up an iExchange account, please go to–and–reference/iexchange, located in the tools section of the provider website.

Payment may be denied if you perform procedures without authorization. If this happens, you may not bill your patients.

As a reminder, it is important to check eligibility and benefits prior to rendering services. This step will help you determine if benefit preauthorization is required for a particular member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSMT’s provider website.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.

eviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSMT. eviCore is wholly responsible for its own products and services. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by eviCore.

AIM Specialty Health (AIM) is an operating subsidiary of Anthem and an independent third party vendor that is solely responsible for its products and services.

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT.

iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers.

BCBSMT makes no endorsement, representations or warranties regarding any products or services offered by Availity, eviCore, AIM or Medecision. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.