Preauthorization
Protecting members is a top priority. Through research and medical policy, developing and implementing guidelines that encourage member safety continues to be necessary. Utilization management programs, such as pre-service reviews and preauthorizations, provide effective ways to manage member safety and the volume of health care services delivered.
BCBSNE has two preauthorization/pre-service programs designed to keep member safety at the forefront. Pre-service reviews allow us to determine if the procedures are medically necessary and/or investigative, according to the stated criteria and medical policy. This preauthorization requirement is applicable to all BCBSNE members (except Medicare Supplement and FEP members).
Access the list of services, procedures and medical policies requiring authorization (certification) prior to providing the service.
Search codes on MedPolicy Blue »
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.
Submit a Preauthorization Online (NaviNet)
In-state providers must submit requests through NaviNet.
Out-of-state providers can create a NaviNet account to submit preauthorizations. Alternatively, you may choose to submit preauthorizations manually via fax or phone. The Preauthorization Request Form is available on our Provider Forms page. After completing the form, please remember to save it. For assistance, you can also call the customer service number on the back of the member's BCBSNE ID card.
Please see our eLearning video, NaviNet Preauthorization, for guidance in submitting and viewing preauthorization and precertification requests.
If you have an urgent request and need immediate assistance, please call 800-635-0579, option 5, to speak with our Customer Service team.
Tips and resources:
Enhance preauthorization webinars and training
Preauthorization Frequently Asked Questions
Gold Card Outpatient Authorization
Checking Status via NaviNet®
To check the status of a preauthorization request submitted via NaviNet, please follow these steps:
- Log in to NaviNet.
- Under Workflows for this Plan, select Preauthorization or Precertification.
- Select the ordering provider and click the submit button.
Note: The rendering facility will be able to view the status only if the ordering provider identified the rendering facility when entering the request in NaviNet.
- Click the Authorization List icon from the menu on the left side of the screen to view the authorizations.
For Preauthorization Requirements
Reminder: To verify if preauthorization is required for a specific procedure code you must utilize the medical policy tool.
Out of Area Members
For out of area members, please select Pre-Service Review for Out of Area Members Workflows.
Additional Help
If your preauthorization request was initially faxed in, you may contact Customer Service at 800-635-0579, Option 5.
For further assistance, please visit our Provider Academy. An eLearning tutorial is available in NaviNet Tips and Tricks.
Please refer to the provider procedure below that outlines the Medicare Advantage (MA) preauthorization requirements.
MA Prior Authorization and Precertification Requirements
The Musculoskeletal (MSK) program is designed to improve quality and manage the utilization of Interventional Pain Management (IPM) procedures and musculoskeletal surgeries.
- Musculoskeletal surgeries are a leading cost of health care spending trends.
- Variations in member care exist across all areas of surgery (care prior to surgery, type of surgery, surgical techniques and tools and post-op care)
- Diagnostic imaging advancements have increased diagnoses and surgical intervention aligning with these diagnoses rather than member symptoms.
- Medical device companies marketing directly to consumers.
- Surgeries are occurring too soon leading to the need for additional or revision surgeries.
Outpatient IPM:
A separate prior authorization number is required for each procedure ordered. A series of injections will not be approved.
- Spinal Epidural Injections
- Paravertebral Facet Joint Injections or Blocks
- Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)
Outpatient and Inpatient Spine Surgeries:
- Lumbar Microdiscectomy
- Lumbar Decompression (include laminotomy, laminectomy, facetectomy, foraminotomy)
- Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single and Multiple Levels
- Lumbar Artificial Disc Replacement -Single and Multiple Levels
- Cervical Anterior Decompression with Fusion (ADCF) –Single and Multiple Levels
- Cervical Posterior Decompression with Fusion – Single and Multiple Levels
- Cervical Anterior Decompression (without fusion)
- Cervical Posterior Decompression (without fusion)
- Cervical Artificial Disc Replacement – Single and Multiple Levels
Evolent (formerly National Imaging Associates, Inc.) does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those listed above.
Please refer the Preauthorization Update for MSK and IPM FAQs and presentation for information
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.
Log into NaviNet