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1 nov, 2021

BCBSMA initiating a new utilization management process

Blue Cross Blue Shield of Massachusetts (BCBSMA) is initiating a new utilization management program for certain services for our Commercial EPO and PPO Members. These requirements have been in place for our HMO and POS membership and this change aligns our EPO and PPO products with them.

Additionally, they are implementing these medical policies for their Medicare Advantage members.

PPO/EPO/Medicare Advantage Authorization requirement changes:

Effective 1 de enero de 2022:

The changes listed below apply to certain services that are covered by their members’ medical benefits.

Prior authorization for commercial EPO, PPO, and Medicare Advantage members:

The following services will have an authorization requirement as of 1 de enero de 2022. BCBSMA will begin accepting authorizations 30 days in advance of the requirement date. Members currently using these services or those having one of the services performed will require an authorization for dates of service on or after 1 de enero de 2022.

servicio
Applies to
Provider can request authorization
Continuous glucose monitors
(Codes: A9277, K0553, S1036)
  • Commercial EPO and PPO
  • Medicare Advantage
By calling the Pre-Authorization number on the back of the member’s card.
Remember: Authorization is required on an annual basis.
Spine surgeries using InterQual
SmartSheets for:
  • Anterior Cervical Discectomy and Fusion (ACDF)
  • Discectomy, Percutaneous, Lumbar
  • Fusion (with Laminectomy), Cervical
  • Fusion (with Laminectomy), Lumbar
  • Fusion (with Laminectomy), Thoracic
  • Fusion, Cervical Spine
  • Fusion, Lumbar Spine
  • Fusion, Thoracic Spine
  • Hemilaminectomy (Laminotomy) +/- Discectomy, Cervical
  • Hemilaminectomy (Laminotomy) +/- Discectomy, Lumbar
  • Laminectomy (with Fusion), Cervical
  • Laminectomy (with Fusion), Lumbar
  • Laminectomy (with Fusion), Thoracic
  • Laminectomy, Cervical
  • Laminectomy, Lumbar
  • Laminectomy, Thoracic
  • Commercial EPO and PPO
By calling the Pre-Authorization number on the back of the member’s card.
Other services (Please see attached document)
Please note the Policy Links will be updated on 1 de enero and an update will be sent when the policies are live.
  • Commercial EPO and PPO
  • Medicare Advantage
By calling the Pre-Authorization number on the back of the member’s card.

Applies to these services.

Authorization is required for these services for dates of services on or after 1 de enero de 2022.

How to request prior authorization

  • Providers can contact the BCBSMA authorization area by calling 1-800-676-BLUE

Please note that:

  • As always, BCBSMA recommends checking benefits and eligibility to determine the member’s benefits and any authorization requirements.
  • All services must continue to meet medical necessity criteria. BCBSMA will only provide reimbursement for services that meet these requirements and for which a prior authorization has been obtained.
  • The Medical Policy Router and the General Pre-Requirements will be updated by 1 de enero de 2022.

The Medical Policies for BCBSMA’s UM program are now posted. Please refer to these links going forward.

servicio
Applies to
Provider can request authorization
Continuous glucose monitors
(Codes: A9277, K0553, S1036)
  • Commercial EPO and PPO
  • Medicare Advantage
By calling the Pre-Authorization number on the back of the member’s card.
Refer to our Continuous or Intermittent
Monitoring of Glucose in Interstitial
Fluid and Artificial Pancreas Device
Systems medical policy 107.
Remember: Authorization is required on an annual basis.
Spine surgeries using InterQual
SmartSheets for:
  • Anterior Cervical Discectomy and Fusion (ACDF)
  • Discectomy, Percutaneous, Lumbar
  • Fusion (with Laminectomy), Cervical
  • Fusion (with Laminectomy), Lumbar
  • Fusion (with Laminectomy), Thoracic
  • Fusion, Cervical Spine
  • Fusion, Lumbar Spine
  • Fusion, Thoracic Spine
  • Hemilaminectomy (Laminotomy) +/- Discectomy, Cervical
  • Hemilaminectomy (Laminotomy) +/- Discectomy, Lumbar
  • Laminectomy (with Fusion), Cervical
  • Laminectomy (with Fusion), Lumbar
  • Laminectomy (with Fusion), Thoracic
  • Laminectomy, Cervical
  • Laminectomy, Lumbar
  • Laminectomy, Thoracic
  • Commercial EPO and PPO
By calling the Pre-Authorization number on the back of the member’s card.
Other services (Please see attached document)
After 1 de enero de 2022 Providers can find this list on
  • Medical Policy #072 Outpatient Prior Authorization Code List for Commercial (HMO POS PPO Indemnity)
  • Medicare Advantage: Medical Policy #132 Medicare Advantage Management
  • Commercial EPO and PPO
  • Medicare Advantage
By calling the Pre-Authorization number on the back of the member’s card.
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