[PDF] [PDF] Post-Acute Care Utilization Program for Blue Cross Blue - eviCore

[PDF] Provider Preauthorization & Precertification Requirements

Commercial Blue Cross Blue Shield of Michigan Products-Non-Medicare Medication Prior Authorization or call 800-437-3803 to obtain criteria and forms

[PDF] Michigan Prior Authorization Request Form for Prescription Drugs

This form will be updated periodically and the form number and most recent revision Prior authorization requests are defined as requests for pre-approval from an insurer for specified Physician's Direct Contact Phone Number ( ) _____-______ □Priority □Magellan □Blue Cross Blue Shield of Michigan □ HAP □ 

[PDF] Medication Prior Authorization Request - Blue Cross Complete of

Note: Blue Cross Complete's prior authorization criteria for a brand-name (DAW) request: Documentation of Name: DOB: ID number: Prescriber information Name: Specialty: Phone: Fax: NPI: Cross Complete of Michigan does not exclude

[PDF] Welcome Provider Packet for BlueCross BlueShield of Michigan

BCBSM/BCN Medical Drug Authorizations Request Provider Welcome Packet Did you know that you can submit your Medical drug prior authorization Complete the attached form as required and fax to number indicated on the form

[PDF] Post-Acute Care Utilization Program for Blue Cross Blue - eviCore

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee Post-acute care pre-authorization forms are available on our web site:  

[PDF] Utilization Management Program Quick Reference Guide - eviCore

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations Lumbar Spine Fusion Prior Authorization Number (TIN), Fax number

[PDF] Authorization Requirements - Blue Cross Blue Shield

For medications requiring prior authorization and phone and fax numbers to request authorization, refer to: o The specific medical policy Access our library of  

[PDF] Medical Drug Prior Authorization Secured Access Application

To ensure forms are processed timely and accurately, complete the form online, print and fax to BCBSM, otherwise processing may be delayed Also include a 

[PDF] Bcbs of michigan prior authorization form - Squarespace

Blue Cross Blue Shield of Michigan uses the following pre-certification and pre- authorization Pain management authorization forms by fax at 313-483-7323

[PDF] bcbs of michigan prior authorization form for dme

[PDF] bcbs of michigan prior authorization form for medication

[PDF] bcbs of michigan prior authorization form for radiology

[PDF] bcbs of michigan prior authorization list

[PDF] bcbs of michigan prior authorization radiology

[PDF] bcbs standard prior authorization form

[PDF] bcp 47 country code

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© 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

Post-Acute Care Utilization Program for

Blue Cross Blue Shield of Michigan

Medicare Advantage PPO

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross® and Blue Shield® Association.

eviCore is an independent company that manages prior authorization for Blue Cross and Blue Shield of Michigan.

Agenda

¾Post-Acute Care Program Overview

¾Pre-Authorization Requirements

¾Denial and Appeals Process

¾Pre-Authorization Submission

¾Post-Acute Care Provider Resources

¾Provider Web Portal -Overview

¾Q & A Session

2 3 eviCore healthcare

Post-Acute Care Program Overview

eviCore healthcare began accepting initial authorization and concurrent review requests on 6/1/2016 for the following provider types:

Skilled nursing facility admissions

Inpatient rehabilitation facility admissions

Long-term acute care admissions

eviCore healthcare manages the following members: Medicare Advantage PPO, also known as BCBSM Medicare Plus Blue (BCBSM Medicare Advantage PPO alpha prefix begins with XYL)

Above members who reside in the state of Michigan

Above members who receive treatment in Michigan facilities Providers should verify member eligibility and benefits on web-DENIS Once the patient is discharged from the post-acute facility, the patient will be referred back to BCBS for continued services 4

Initial Post-Acute Care Admission Requests

Pre-Authorization Overview

Hospital initiates pre-authorization requests:

The hospital is responsible to submit post-acute care pre-authorization requests, unless the post-acute care facility (i.e. IRF) has the same NPI or Tax ID # eviCore requests that you start the process as soon as possible to facilitate a timely pre- authorization determination

Discharge

Planning

Begins on day 1 of

Hospital admission

Hospital staff makes a

recommendation for post- acute level of care

Contact

eviCore

Provide pre-authorization

form and clinical information to support medical necessity for admission to post-acute level of care

Utilization

Management

Three outcomes:

Approval of pre-authorization for

level of care request

Request for additional clinical

information

Unable to approve on initial UM

review

Our goal is a 24-48 hour response time;

add an additional 2 business days if a peer to peer review is requested, however our typical response time is less Post-acute care pre-authorization forms are available on our web site: https://www.evicore.com and implementation web site:https://www.evicore.com/healthplan/BCBSM 5

Date extension (PAC concurrent review) Requests

Overview

The PAC facility is responsible to submit date extension (concurrent review) requests eviCore requests that you start the date extension review process as soon as possible to

Plan of Care

& Discharge

Planning

Begins on day 1 of Post-

Acute Care admission

Care management team

completes evaluations and begins to develop a plan of care

Contact

eviCore

Provide pre-authorization

form and clinical information to support medical necessity for post- acute level of care

Utilization

Management

Three outcomes:

Approval of pre-authorization for

level of care request

Request for additional clinical

information

Unable to extend authorization

Our goal is a 24-48 hour response time, once clinical information is received; add an additional 2 business days if a peer to peer review is requested, however our typical response time is less Important: SNF Facilities should submit clinical for date extension (PAC concurrent review) pre-authorization requests 72 hours prior to the last covered day to allow time for Notice of Medicare Non-Coverage (NOMNC) to be issued. The provider is responsible to issue the NOMNC, have it signed and returned to eviCore 6

Post-Acute Care Facility Authorization Overview

eviCore will provide authorizations by facility type in the following ways:

Pre-Authorization Expiration

The initial authorization expires 10 days from the date of issue If the patient is not discharged within this time frame, a new authorization is required

Post Acute Care Admission Authorization Criteria

Initial UM Nurse Review -McKesson IQ

2nd level MD Review -Medicare Benefit Policy Manuals & Clinical Findings

Once Determination is Complete:

a notification will be communicated to the requesting provider servicing providers may obtain authorizations via the eviCore web portal or by calling eviCore @ 1-877-917-2583 (Blue)

AuthorizationSkilled Nursing

Facility

Inpatient Rehab

Facility

Long Term Acute

Care Initial3 business days5 calendar days5 calendar days Concurrent7 calendar days5 calendar days7calendar days 7 eviCore healthcare Post-Acute

Care Pre-Authorization

Required Information

Blue Cross Blue Shield of Michigan

8 Required Information for InitialPAC Pre-Authorization

Admission

Details

Facility type being requested

Accepting Facility demographics

Patient demographics

Start of care date

Clinical

Information

Hospital admitting diagnosis

History & Physical

Progress Notes, i.e. Attending physician, Consults & Surgical (if applicable)

Medication list

Wound or Incision/location and stage (if applicable)

Mobility and

Functional

status

Prior and Current level of functioning

Therapy evaluations PT/OT/ST

Therapy progress notes including level of participation Please note: Pre-Authorization forms are required for all

Post-Acute Care pre-authorization requests

9

Required Information for Date Extensions

(PAC concurrent review requests) Pre-

Authorization

Details

Facility type and demographics

Patient demographics

Number of days and dates requested

PAC physician demographics

Anticipated date of discharge

Clinical

Information

Hospital admitting diagnosis and ICD10 code

Clinical Progress Notes

Medication list

Wound or Incision/location and stage (if applicable)

Discharge summary (when available)

Mobility and

Functional status

Prior and Current level of functioning

Focused therapy goals: PT/OT/ST

Therapy progress notes including level of participation Discharge plans (include discharge barriers, if applicable) Please note: Authorization forms are required for all

Post-Acute Care authorization requests

10 eviCore healthcare

Post-Acute Care

Denial and Appeals Process

Blue Cross Blue Shield of Michigan

11

Unable to Pre-

eviCore Process Cases that do not meet Medical Necessity on Initial UM Nurse review will be sent to 2nd level MD for review and determination If potential adverse determination is made by MD, outreach is made to the requesting provider and a Peer to Peer Review is offered

Initial Pre-Authorization

Request

Peer to Peer (P2P) must be requested within 1 business day or additional clinical information that supports medical necessity must be received within 1 business day or the determination is final and the case will be closed Note: P2P must occur within 2 business days or a denial letter will be issued.

Authorization Denial

If the P2P process does not result in a reversal of the recommendation of denial, eviCore will issue a denial letter. The physician reviewer may suggest an alternate level of care and/or the appeals process.

Appeals Process

Once a service has been denied, members and providers must file an appeal with

BCBSMI to have the request re-reviewed.

Contact BCBSMI at 866-309-1719 orwww.bcbsm.com

Members requesting to appeal a denial for initial PAC services should contact BCBSMI.

Instructions are provided on the denial letter.

12 eviCore Process Cases that do not meet Medical Necessity on concurrent UM Nurse review will be sent to 2nd level MD for review and determination if the provider or attending PAC Physician are in disagreement with the decision to end skilled care If a potential adverse determination is made by MD, outreach is made to the PAC provider and a P2P review may requested

Inpatient Rehabilitation

Facility (IRF)

Date Extensions

Peer to Peer (P2P) must be requested within 1 business day or additional clinical information that supports medical necessity must be received within 1 business day or the determination is final and the case will be closed. Note: P2P must occur within 2 business days or a denial letter will be issued.

SNF Date Extensions

(PAC concurrent review requests) The Notice of Medicare Non-Coverage (NOMNC) will be issued no later than 2 calendar days prior

to the discontinuation of coverage. The third calendar day will not be covered unless the decision is

overturned or the NONMC is withdrawn P2P must be requested and occur within the 2 calendar day timeframe. If P2P does not occur or if the decision is upheld, the member is responsible to pay for the continued stay if they choose not to discharge on the 3rd calendar day.

Member Appeals Process

Members requesting to appeal the decision to end skilled care in a SNF facility should follow the QIO process as outlined on the NOMNC and contact BCBSMI. Members requesting to appeal a denial based on the decision to end skilled care for concurrent IRF services should contact BCBSMI. Instructions are provided on the denial letter.

© 2015 eviCore healthcare. All Rights Reserved. This presentation contains CONFIDENTIAL and PROPRIETARY information.

Pre-Authorization Submission

Methods for Post-Acute Care

Blue Cross Blue Shield of Michigan

Authorization

Call Center

What we need

Pre-Authorization Requests for Post-Acute Care

Hours of Operation

eviCore offers four methods to request pre-authorizations:

1.eviCore Post-Acute Care Web (preferred method):

2. Fax: Clinical documentation can be faxed to:

844-407-5293 Please send information for onepatient

per fax.

3. Allscripts: eviCore can accept pre-authorization

requests and respond to providers who use Allscripts

4. Telephone: Clinical information can be called to eviCore

healthcare at1-877-917-2583 and choose option 1. 14 Hours of Operation that eviCore staff is available:

Monday through Friday 8 a.m. to 7 p.m. EST

Saturday 10 a.m. to 5 p.m. EST

Sunday 10 a.m. to 2 p.m. EST

Holidays 10 a.m. to 4 p.m. EST

Authorization

Center

Allscripts

Pre-Authorization Requests for Post-Acute Care

Allscripts

15

To use Allscripts:

2 3 provider name at the bottom make sure nothing is checked and always choose

4) Hit next. When you do, the listing comes up.

eviCore will either respond with a pre-authorization, request additional clinical information or provide notification of case status via Allscripts (i.e. sent to 2nd level review) Providers should be sure and enter their fax number on the pre-authorization form to receive authorization letters and/or denial letters from eviCore

Allscripts Instructions:

Allscripts users should be sure to communicate the name of thequotesdbs_dbs4.pdfusesText_7