Prior Authorizations and Pre-Service Reviews

Prior Authorizations and Pre-Service Reviews

At Blue Cross and Blue Shield of Nebraska (BCBSNE), 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 prior authorizations, provide effective ways to manage member safety and the volume of health care services delivered.

In 2015, BCBSNE introduced two prior authorization/pre-service programs designed to keep member safety at the forefront. Continue reading to learn more about these programs, in addition to our prior authorization requirement, which will go into effect Jan. 1, 2016: 

Prior Authorization Requirement – Effective Jan. 1, 2016

Starting Jan. 1, 2016, as part of our utilization management program, BCBSNE will require prior authorization for certain procedures and services addressed in BCBSNE medical policy. This pre-service review allows us to determine if the procedures are medically necessary and/or investigative, according to the stated criteria and medical policy.  This prior authorization 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 here

It is also important to note that, as part of this Jan. 1, 2016 change, all investigative denials will be considered provider liability, even if a prior authorization is done and denied as being investigative. These types of denials are currently considered member liability. 

Per BCBSNE’s provider policies and procedures, a provider may only hold a member (covered person) 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 reimburse the provider, 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.


Prior Authorization FAQ

Have questions about prior authorization requirements? Review a list of frequently asked questions and get some answers!


NIA Magellan Spine Pain Management – Effective Sept. 1, 2015

In keeping with our commitment to member safety and promoting continuous quality improvement for services, BCBSNE has entered into an agreement with National Imaging Associates, Inc. (NIA), to implement a spine pain management program, effective for procedures performed on or after Sept. 1, 2015.  NIA, a Magellan Health Services company, is an industry-leading organization that delivers innovative solutions for effective health care management.

This program includes prior authorization for two components of non-emergent spine care – outpatient interventional pain management (IPM) services, and inpatient and outpatient cervical and lumbar spine surgeries – for all BCBSNE members, excluding those covered by the following groups or products:

  • Federal Employee Program
    • Basic plan with no out-of-network coverage
    • Standard plan with out-of-network coverage
  • Medicare Supplemental
  • Nebraska Department of Correctional Services
  • Nebraska Department of Health and Human Services
  • University of Nebraska student athletes

BCBSNE will oversee the program and continue to be responsible for claims adjudication and medical policies. NIA Magellan will manage non-emergent, outpatient IPM services, along with inpatient and outpatient cervical and lumbar spine surgeries.

Additional Information

Sinus Surgeries, Hysterectomies and Endometrial Ablations – Effective April 15, 2015

Over the past few years, BCBSNE has noted increased utilization in clinical areas such as hysterectomies and sinus surgeries. This increase has led to concerns that members may be undergoing unnecessary surgical procedures, which impacts patient safety.

To that effect, BCBSNE now requires a pre-service review for BCBSNE members and their dependents (excluding FEP and Medicare Supplement members) for the following procedures:

  • Endometrial ablations
  • Hysterectomy
  • Hysteroscopy
  • Sinus surgeries

As part of the prior authorization process, BCBSNE will use nationally vetted medical necessity criteria from McKesson. McKesson uses InterQual® criteria, which influences appropriate care with rule-based, patient-specific decision support using evidence-based medicine.

Additional Information
Precertification/Preauthorization Requirements

HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.