MA Prior Authorization and Precertification Requirements

We display one prior authorization list for all Medicare Advantage plans. Please see list of codes below for all services requiring a prior authorization for procedures, radiology and surgeries.    

We contract with Evolent for spine surgeries (cervical and lumbar spine fusions) and Interventional pain management services.

Please submit PA request directly to Evolent

• Hours of Operation: 7 a.m. - 7 p.m. (CST) (8 a.m. - 8 p.m. EST). 
• Call toll free 1-866-972-9642  
• Website RadMD.com 

Please use the provider portal through Navinet^® at NaviNet.net to login or NaviNet Registration for all other prior authorization requests

• Diagnostic procedures/tests 
• Advanced Radiology services 
• Durable medical equipment 
• Ambulatory/outpatient surgical services  
• Ground and air ambulance 
• Medical supplies  
• Prosthetic devices  
• Laboratory services 
• Transplants  
• Acupuncture 
• Out of Network Services (applies to HMO) 

Please use the provider portal through Navinet at NaviNet.net to login or NaviNet Registration for all inpatient prior authorizations: 

• Acute and inpatient admissions (including behavioral health)
• Inpatient rehabilitation admissions
• Skilled nursing facility admissions (SNF)
• Long Term Acute care admissions (LTACH)
• Home Health Services (including PT, OT and ST)
• 30 days bundling for readmissions 
• Out of Network Inpatient stay (applies to HMO) 

Please note: Per CMS, expedited requests should ONLY be requested when the health care provider believes that waiting for a decision under the standard review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function. Please be mindful of this definition when submitting your requests so that we can prioritize and process all requests appropriately.  

BCBSNE follows CMS coverage guidance when reviewing codes when available. CMS coverage documents, including National Coverage Determinations and Local Coverage Determinations, can be found by using the CMS Medicare Coverage Database search tool. BCBSNE also uses Interqual® clinical criteria and medical policies. For more information, please review the BCBSNE MA Provider Procedures searchable tool on NebraskaBlue.com/Providers/BCBSNE-Provider-Procedures.

*Please see the Medicare Advantage Part B prior authorization list for medications.

Ablation of Peripheral Nerves

Acupuncture

Advanced Radiology

Ambulatory Cardiac Event Monitors

Benign Prostate Hyperplasia

Cardiac Catheterization

Computer Assisted Navigation

CAR T Cell Therapy*

Cosmetic and Reconstructive Surgery

Drug Eluting Sinus Implants

Electrophysiology Testing and Cardiac Ablation

Gender Dysphoria Treatment

Home Health Services

Implantable Bone Conduction and Bone Anchored Hearing Aid

Labs and Genetic Testing

LCD or NCD procedures for Experimental and Investigational and/or Medical Necessity Review and InterQual criteria

Non-Coronary Vascular Stents

Non-invasive Cerebrovascular and peripheral arterial vascular studies

Percutaneous Coronary Intervention (PCI)

Permanent Cardiac Pacemaker and Defibrillators

Prostate Rectal Spacers

Tissue Transfer Flaps

Transesophageal (TEE)

Orthognathic Surgery

Urinary Incontinence Treatment

Evolent Spine and Pain Management Codes

Myoelectric Limb Prosthesis

Neurostimulators

Non-Emergent Ambulance and Air Ambulance

Percutaneous Disc Procedures

Prosthetics

Radiation Oncology

Sleep Studies

Transplants - Bone Marrow Harvest

Transplants - Heart/Lung

Transplants - Heart

Transplants - Lung

Transplants - Kidney

Transplants - Pancreas

Transplants - Liver

Transplants - Intestine

Other Services Related to Transplants

Vein Ablation/Surgery

Durable Medical Equipment