New Medicare Advantage Preauthorization Requirements through eviCore
Effective June 1, 2017, Blue Cross Blue Shield of Montana (BCBSMT) has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide preauthorization services for the following benefit plan(s):
- Blue Cross Medicare Advantage (PPO) SM
- Blue Cross Medicare Advantage (HMO) SM
eviCore will manage preauthorization services for the following specialized clinical services:
- Outpatient Molecular Genetics
- Outpatient Radiation Therapy
- Physical and Occupational Therapy
- Speech Therapy
- Spine Surgery (Outpatient/Inpatient)
- Spine Lumbar Fusion (Outpatient/Inpatient)
- Interventional Pain
- Outpatient Cardiology & Radiology
- Abdomen Imaging
- Cardiac Imaging
- Chest Imaging
- Cardiac Rhythm Implantable Device (Crid)
- Head Imaging
- Neck Imaging
- Oncology Imaging
- Pelvis Imaging
- Peripheral Nerve Disorders (Pnd) Imaging
- Peripheral Vascular Disease (Pvd) Imaging
- Spine Imaging
- Outpatient Medical Oncology
- Outpatient Sleep
- Post-Acute Care
- Outpatient Specialty Drug
Services performed without preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek reimbursement from the member.
You will continue to use iExchange® for all other services that require preauthorization.
BCBSMT and eviCore will be providing additional information, including training opportunities, in the coming months on the Provider website at bcbsmt.com/provider and in Blue Review. You may also contact your Provider Network Representative for more information.
Provider Network Representative Contact Information:
Floyd Khumalo, 406-437-5248, Thamsanqa_f_Khumalo@bcbsmt.com
Susan Lasich, 406-437-6223, Susan_Lasich@bcbsmt.com
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSMT.
Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable plan. Preauthorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member's policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.