New Medicare Advantage Preauthorization Requirements through eviCore

Apr. 03, 2017

*Update to the article posted on February 2, 2017

The new effective date for the Medicare Advantage preauthorization requirement through eviCore will be 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
  • Musculoskeletal
    • Chiropractic
    • 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
    • Head Imaging
    • Musculoskeletal
    • Neck Imaging
    • Oncology Imaging
    • Pelvis Imaging
    • Peripheral Nerve Disorders (Pnd) Imaging
    • Peripheral Vascular Disease (Pvd) Imaging
    • Spine Imaging
  • Outpatient Medical Oncology
  • Outpatient Sleep
  • 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:

Western Region

Christy McCauley, 406-437-6068, Christy_McCauley@bcbsmt.com
Leah Martin, 406-437-6162, Leah_Martin@bcbsmt.com

Central Region

Floyd Khumalo, 406-437-5248, Thamsanqa_f_Khumalo@bcbsmt.com

Eastern Region

Susan Lasich, 406-437-6223, Susan_Lasich@bcbsmt.com
Laura Knaff, 406-437-6961, Laura_Knaff@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.