Preauthorization

Access the list of services, procedures and medical policies requiring authorization (certification) prior to providing the service.

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View the Preauthorization List

All investigative denials will be considered provider liability, even if a preauthorization is done and denied as being investigative. 

Per our BCBSNE Provider Procedures, a provider may hold a member financially liable for a medical necessity or investigative denial only if:

• The provider has advised the member – prior to services being provided – that he or she may be financially liable for the services provided
• The provider must give the member an estimate of financial liability

For a situation where a patient requests services considered not medically necessary and/or investigative and agrees in writing to be responsible for the non-covered charges, the provider must file a paper claim with the signed patient waiver. If a claim is filed without a waiver and the claim is denied as provider liability (but a waiver was signed prior to the claim being filed), a provider may submit a reconsideration with the waiver.

If a written agreement cannot be obtained, verbal notification may be given by the provider. The verbal notification must be documented in the patient’s medical records at the time the notification is given, and evidence provided to BCBSNE. For all other balances, the provider agrees not to bill or collect any amount from the member.

The most efficient way to expedite a preauthorization is to submit your request online. You can also fax your request with medical rationale.

With increased utilization in clinical areas such as sinus surgeries, there is concern that members may be undergoing unnecessary surgical procedures, which impacts patient safety.

To that effect, BCBSNE requires a preauthorization for BCBSNE members and their dependents (excluding FEP and Medicare Supplement members) for the following procedures:

• Hysterectomy
• Sinus surgeries

In keeping with our commitment to member safety and promoting continuous quality improvement for services, BCBSNE partners with National Imaging Associates, Inc. (NIA), for a spine pain management program. NIA is an industry-leading organization that delivers innovative solutions for effective health care management.

This program includes preauthorization for two components of non-emergent spine care for all BCBSNE members: outpatient interventional pain management services, and inpatient and outpatient cervical and lumbar spine surgeries.

Note: The Federal Employee Program, Medicare Supplement, Nebraska Department of Correctional Services, and the Nebraska Department of Health and Human Services are excluded from this program.

BCBSNE oversees the program and continues to be responsible for claims adjudication and medical policies. NIA manages non-emergent, outpatient interventional pain management services, along with inpatient and outpatient cervical and lumbar spine surgeries.

To submit a pre-service review with Magellan, call toll free 866-972-9642 from 7:00 am- 7:00 pm (CST) and you can visit their website at www.RadMD.com

Additional resources:

• Interventional Pain Management Frequently Asked Questions
• Spine Surgery Program Frequently Asked Questions
• Spine Pain Management Quick Reference Guide

_{NIA is an independent entity providing care management services for Blue Cross and Blue Shield of Nebraska.}

The following radiology services require a preauthorization:

• Computed Tomography (CT/CTA)
• Magnetic Resonance Imaging (MRI/MRA)
• Nuclear Cardiology
• Positron Emission Tomography (PET)

Note: Plain radiology films, imaging studies performed in conjunction with emergency room services and inpatient hospitalizations are excluded from this requirement.

Without an approved preauthorization, claims may be denied and you may be responsible for payment of the charges. Please submit all radiology preauthorization requests via NaviNet.

BCBSNE requires precertification for all acute (non-emergency) inpatient and observation admissions to hospitals or facilities on or before the first day of admission. Unplanned admissions can be submitted the first business day following admission.

To submit a precertification, visit Navinet or if you are an out of state provider, please call 800-247-1103.