General Preauthorization Overview Capital BlueCross Effective Date: October 1, 2015 Revised: September 30, 2015 Preauthorization Contact Information: Clinical Management Behavioral Health (Magellan Health Services, Inc. 1 ) Capital BlueCross Behavioral Health (Magellan Health Services, Inc.) Keystone Health Plan Central (KHP Central), SeniorBlue HMO, and SeniorBlue Chiropractic Services (American Specialty Health Group, Inc. 2 ) High-Tech Imaging Services (National Imaging Associates, Inc. [NIA ] 3 ) Radiation Oncology Services (National Imaging Associates, Inc. [NIA ]3) 1.800.471.2242 8 a.m. to 5 p.m. (EST) M F Fax 717.540.2171 Fax 1.866.805.4150 1.866.322.1657 24 hours a day, 7 days a week 1.800.216.9748 8 a.m. to 7 p.m. (EST) M F Emergency/Urgent: 24/7 1.800.972.4226 10 a.m. to 9 p.m. (EST) M F 1.888.203.1423 8 a.m. to 8 p.m. (EST) M F 1.888.203.1423 8 a.m. to 8 p.m. (EST) M F Preauthorization. To submit letters of medical necessity, preauthorization requests, and skilled nursing visit therapy plans. To submit request for Biological Injectables. BH (MH/SA) clinical management issues and BH (MH/SA) authorizations for BH (MH/SA) case management. BH (MH/SA) benefit information, BH/(MHSA) authorizations, and BH (MH/SA) network providers. Chiropractic benefits information, chiropractic authorizations, chiropractic network providers for Traditional, Comprehensive,, POS, and SeniorBlue customers. Preauthorization of certain high-tech imaging procedures for, POS, Comp, KHP Central, SeniorBlue HMO and SeniorBlue customers. ***FEP preauthorization completed by CBC. Preauthorization of Radiation Oncology Services for, POS, Traditional, Comp, KHP Central, SeniorBlue HMO, and SeniorBlue customers. To confirm if service(s) require preauthorization for a specific member, please utilize our online preauthorization application accessible via NaviNet. Access Capital BlueCross NaviNet home page, Select Preauthorization from the left-hand side of the screen, then Outpatient Services. Complete steps 1 4. This will provide you with a coverage determination. If the coverage determination indicates preauthorization is required, you will be able to proceed by completing steps 5 and 6 to submit your preauthorization request for that service. If you need assistance using the online system, please refer to the Provider Library via NaviNet, Training and Manuals, Online Preauthorization Resources or contact your Provider Relations Consultant. 1 On behalf of Capital BlueCross, Magellan Health Services, Inc. assists in the administration of behavioral health benefits. Magellan Health Services, Inc. is an independent company. 2 On behalf of Capital BlueCross, American Specialty Health Group, Inc. assists in the administration of chiropractic benefits. American Specialty Health Group is an independent company. 3 On behalf of Capital BlueCross, National Imaging Associates, Inc. (NIA ), assists in the administration of radiology benefits. National Imaging Associates is an independent company. ald/w1/9076/1.docx (9/30/2015)
Reminders and Variations: Investigational and/or experimental treatments and procedures are not usually covered benefits and require prior authorization in all cases, even if there is no established procedure code. A single document cannot reflect all exceptions, variations, and specific employer group requirements. Therefore, Capital BlueCross suggests that practitioners making a specific request for services that might require preauthorization, based on the standard Preauthorization List (see below) but where codes cannot be found on this list of procedure codes verify benefits and authorization requirements prior to providing services to a customer. The process for the submission of referrals or requests for prior authorization is unchanged. It is important to note that some employer groups for which Capital BlueCross provides administrative services only (self-insured, employer sponsored programs) may customize their plans with different requirements. Selected services may be managed and/or authorized by organizations other than Capital BlueCross. Please refer to the customer ID card for these variations and for contact information. When a Capital BlueCross contracted provider fails to obtain the required preauthorization for a service requiring preauthorization, the entire claim will be deemed not payable and will be denied because the other charges on the claim services typically are related to, and are covered by, the service or supply requiring preauthorization. Behavioral Health Services: Please refer to the customer s insurance card for preauthorization related to Behavioral Health and Substance Abuse benefits and preauthorization phone numbers. Chiropractic Services: Chiropractic services for the following products are preauthorized by American Specialty Health Group, Inc. (ASH) 1.800.972.4226. POS Traditional/Comprehensive SeniorBlue Pennsylvania Employees Benefit Trust Fund (PEBTF) ald/w1/9076/2.docx (9/30/2015)
FEP Variations: All inpatient admissions require preauthorization. Hospice requires preauthorization. The following codes, when performed in a facility, require preauthorization by Capital BlueCross. If performed in a setting other than a facility, please contact Highmark SM for authorization: Surgery for Morbid Obesity Procedure Codes 43644, 43645, 43770, 43842, 43843, 43845, 43846, 43847, 43848, 43888. Oral/Maxillofacial HCPCS: S2083 20605, 21010, 21026, 21030, 21031, 21032, 21034, 21037, 21040, 21044 21047, 21048 21049, 21050, 21060, 21070, 21073, 21116, 21240 21243, 21480 21485, 21490, 29800, 29804, 40490, 40500, 40510, 40520, 40525, 40527, 40530, 40650, 40808, 40800 40801, 40804 40806, 40810, 40812, 40814, 40816, 40819, 40820, 40840, 40842 40845, 40860 40831, 41000, 41005 41010, 41015 41018, 41100, 41105, 41108, 41110, 41112 41116, 41120, 41130, 41150, 41250 41252, 41520, 42000, 42100, 42104, 42106 42107, 42120, 42140, 42145, 42160, 42300 42320, 42330, 42335, 42340 Congenital Anomalies 33813 33814, 40700 40761, 42200 42225, 50070, 50135, 50405, 61680 61692, 61710, 63250 63252. HCPCS: C8921 ald/w1/9076/3.docx (9/30/2015)
Surgery for IMRT Procedure Codes 0073T, 77301, 77385, 77386, 77418, G6015 or G6016 No Preauth required if dx:140-149.9, 160.0, 160.2-160.5, 161.0-161.9, 174-174.9, 175.0-175.9 or 185 C000, C001, C002, C003, C004, C005, C006, C008, C009, C01, C020, C021, C022, C023, C024, C028, C029, C030, C031, C039, C040, C041, C048, C049, C050, C051, C052, C059, C060, C061, C062, C0680, C0689, C069, C07, C080, C081, C089, C090, C091, C099, C100, C101, C102, C103, C104, C108, C109, C110, C111, C112, C113, C118, C119, C12, C130, C131, C132, C138, C139, C140, C142, C148, C300, C310, C311, C312, C313, C320, C321, C322, C323, C328, C329, C50011, C50012, C50019, C50021, C50022, C50029, C50111, C50112, C50119, C50121, C50122, C50129, C50211, C50212, C50219, C50221, C50222, C50229, C50311, C50312, C50319, C50321, C50322, C50329, C50411, C50412, C50419, C50421, C50422, C50429, C50511, C50512, C50519, C50521, C50522, C50529, C50611, C50612, C50619, C50621, C50622, C50629, C50811, C50812, C50819, C50821, C50822, C50829, C50911, C50912, C50919, C50921, C50922, C50929, or C61., 195.0, 196.0, 198.91, 171.0,230.0, 233.0, 233.4, 154.2. 154.3 PEBTF Variations: DME authorized by DMEnsions 1.888.732.6161. PEBTF Traditional Initial six (6) visits do not require preauthorization for Physical Medicine and Occupational Therapy. PEBTF Traditional Speech Therapy requires preauthorization starting with the seventh (7th) visit. Non-Specific (NOC) Codes Please be aware that many NOC codes do not require preauthorization all NOC codes are subject to retrospective claims review and must be submitted with a description of the actual service provided. ald/w1/9076/4.docx (9/30/2015)
No Guarantee of Coverage Coverage is determined by medical necessity, the customer s benefit plan, and the customer s eligibility at the time the services were rendered. If you have questions about a customer s coverage, visit the Capital BlueCross health plan home page via the NaviNet 4 portal. You can enroll with NaviNet by accessing: connect.navinet.net/enroll, or call the Capital BlueCross Customer Service Call Center at 1.866.688.2242 (Professional) or 1.800.753.1276 (Facility). This list is subject to change with notification. SERVICE PERSONALBLUE INDIVIDUAL ACCT TRAD/COMP/ POS KHPC 5 SB HMO SB Admissions (Acute, LTACH, SNFs, Rehabs) Non-Emergency Admissions (Behavioral Health, Substance Abuse, and/or Partial Hospitalizations) (See Customer ID card for preauthorization contact information.) N/A Ambulance (Non-Emergent), Air Ambulance (Non-Emergent) Aqueous Drainage Devices for Glaucoma Behavioral Health/Substance Abuse (Outpatient) (See Customer ID card for preauthorization contact information.) N/A Behavioral Health/Substance Abuse (Intensive Outpatient Programs) (See Customer ID card for N/A preauthorization contact information.) Behavioral Health (Outpatient) ABA Services for Autism Spectrum Disorders N/A N/A N/A Biological and Burn Wound Dressings Category IDE (Investigational Device Exemptions) Trials Cardiac Nuclear Medicine Studies, including Cardiac Stress Tests Clinical Trials (Including Cancer-Related Trials) * SeniorBlue HMO and SeniorBlue : Clinical trials do not require preauthorization; however, providers must verify that the clinical trial is Medicare approved. * * Cosmetic/Reconstructive DME, Prosthetics, and Orthotics Preauthorization is required for: (1) all purchases and repairs where the unit charge is equal to or greater than $500 per unit and (2) all rentals regardless of price per unit require preauthorization. (Note: Group-specific requirements may exist.) Enhanced External Counterpulsation (EECP) Eye Injections (Intravitreal Angiogenesis Inhibitors) Genetic Testing All testing for genetic disorders requires preauthorization except for: (1) standard chromosomal tests, such as Down Syndrome, Trisomy, and Fragile X, and (2) state mandated newborn genetic testing. Home Health Preauthorization is required prior to the home evaluation visit and/or the first visit (except for mandated home health visits for mastectomies and maternity). 4 NaviNet is an independent company providing this provider portal service on behalf of Capital BlueCross. ald/w1/9076/5.docx (9/30/2015)
SERVICE PERSONALBLUE INDIVIDUAL ACCT TRAD/COMP/ POS KHPC 5 SB HMO SB Home IV Therapy Preauthorization is required prior to the home evaluation visit and/or the first visit. Hyperbaric Oxygen (HBO) Therapy (Non-Emergent) Imaging Procedures All high tech, nonemergent MRIs, MRAs, CTs, PETs, SPECTs, and all cardiac nuclear medicine studies, including cardiac stress tests. Radiation oncology CT (computed tomography guidance for placement of radiation therapy fields) does not * require preauthorization. *Traditional: Preauthorization is not required for high tech radiology services. Intraocular Injections for Retinal Pathology Performed in a Facility Investigational/Experimental Surgeries, Therapies, and Procedures Laser Treatment of Skin Lesions Manipulation (Chiropractic and Osteopathic) Therapy Traditional,, and POS: Preauthorization is required after the first six visits per benefit period. POS: Manipulation therapy performed by the customer s Physician of Choice does not require preauthorization. Keystone Health Plan Central HMO, SeniorBlue HMO, and SeniorBlue : Preauthorization is required prior to an initial evaluation visit and/or the first therapy visit. Manipulation therapy performed by the customer s Physician of Choice does not require preauthorization. Mohs Surgery, when performed on two separate days by the same provider Observational Care Admissions Out-of-Network (OON) and/or Noncontracted Providers Traditional, : All care rendered by OON/noncontracted providers for services that are on this preauthorization list must be preauthorized. Services rendered by OON/noncontracted providers will be paid at a reduced benefit level as defined by contract. POS: All care rendered by OON/noncontracted Providers for services that are on this preauthorization list must be preauthorized. Services rendered by OON/noncontracted providers must be preauthorized if the services are to be considered for the full benefit coverage level as defined by contract. Keystone Health Plan Central HMO and SeniorBlue HMO: Preauthorization is required. SeniorBlue : All care rendered by OON/noncontracted providers does not require preauthorization, however services may be reviewed post-service for medical necessity. Office Surgical Procedures When Performed in a Non-Office Setting Arthrocentesis; aspiration of a joint; colposcopy; electrodesiccation condylomata complex; excision of a chalazion; excision of a nail partial or complete; enucleation or excision of external thrombosed hemorrhoids; injection of a ligament or tendon; intravitreal injections; oral surgery; pain management (including facet joint injections, trigger point injections, stellate ganglion blocks, peripheral nerve blocks, SI joint injections, and intercostal nerve blocks); proctosigmoidoscopy/flexible sigmoidoscopy; removal of partial or complete bony impacted teeth (if a benefit); repair of lacerations, including suturing (2.5 cm or less); vasectomy; wound care and dressings (including OP burn care). Outpatient Surgeries Including reconstructive/cosmetic and investigational/experimental surgeries. ald/w1/9076/6.docx (9/30/2015)
SERVICE Private Duty Nursing Not a standard covered benefit and group specific requirements may exist. Preauthorization is required if a nonstandard benefit. Pulmonary Rehabilitative Programs Preauthorization is required prior to the home evaluation visit and/or the first visit. Radiation Therapy and related treatment planning and procedures performed for planning (such as but not limited to IMRT, proton beam, neutron beam, brachytherapy, 3D conform, SRS, SBRT, Gamma knife, EBRT, IORT, IGRT) PERSONALBLUE INDIVIDUAL ACCT TRAD/COMP/ POS KHPC 5 SB HMO SB N/A Radiofrequency Ablation for Pain Management Rehabilitative Therapies Including: Occupational Therapy, Respiratory Therapy, and the following Physical Medicine therapies: Physical Therapy, Vestibular Therapy, Vision Therapy, Urinary Incontinence, Biofeedback, and Wound Care. Preauthorization is required prior to an initial evaluation visit and/or the first therapy visit. * PEBTF Traditional requires PA after the 6th visit for PM, OT, RT, and ST. * Sleep Studies in a facility Specialty Medical Injectables Transcranial Magnetic Stimulation (TMS) Transplant Evaluations and Services SERVICES REQUIRING A REFERRAL ( YES ) POS KHP CENTRAL HMO SENIORBLUE HMO DIRECT ACCESS 6 Specialty office visits Durable medical equipment, prosthetics, and orthotics All purchases/repairs where the unit cost is less than $500 Diabetes education/training (Note: For SeniorBlue HMO this also includes renal disease education/training.) Endoscopy Including colonoscopy studies Nutritional Counseling OB/GYN services (Routine) No No No No OB/GYN services (Non-Routine) * For SeniorBlue, routine women s health care, including breast exams, mammograms, pap tests, and pelvic exams when received from a participating No No Yes* No provider, does not require a referral. However, for SeniorBlue other OB/GYN services require a referral. Outpatient surgeries and services not requiring preauthorization See preauthorization table for list of outpatient surgeries and services requiring preauthorization. Sleep studies Referral required for OON provider use Speech Therapy No No Yes No 5 KHPC (KHP Central) includes the Direct Access benefit option. 6 Direct Access is a benefit option for KHP Central HMO. ald/w1/9076/7.docx (9/30/2015)