October 2016

New Prior Authorization Requirements for Blue Cross and Blue Shield of Nebraska Members

Blue Cross and Blue Shield of New Mexico (BCBSNM) is committed to providing recent news and updates to processes and requirements that may affect our participating providers and Bluecard^® members.

For participating providers who are offering services to Blue Cross and Blue Shield of Nebraska (BCBSNE) members, the following preauthorization requirements have gone into effect, Oct. 1, 2016.

Participating providers must receive preauthorization*, including preservice review, for the following services:

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

Please note, plain radiology films, imaging studies performed in conjunction with emergency room services, observation care and inpatient hospitalizations are excluded from this requirement.

This preauthorization requirement aligns with BCBSNE’s commitment to protect members and to ensure the medical necessity and appropriateness of procedures and services for our members.

Why is this important to BCBSNM participating providers?
Some BCBSNE members reside outside Nebraska. It is important to note that BCBSNE does not have contractual agreements with out-of-state providers. BCBSNM participating providers may not be aware of the preauthorization requirements for certain services offered to BCBSNE members.

Beginning Oct. 1, 2016, if preauthorization is not obtained for the services listed above for BCBSNE members, claims may be denied and BCBSNE members may be responsible for payment. BCBSNE out-of-state members have been informed of this policy change and how it affects them.

Also, if a preservice review is submitted – but not approved – and the service is provided, members may be held liable for charges for services determined not medically necessary.

To avoid possible claims denial and member financial responsibility for the charges if a preservice review is not completed, submit all preservice reviews and preauthorization requests to BCBSNE.
Preauthorization may be obtained by contacting the BCBSNE nurse line at (888) 236-3870 or by submitting requests electronically through Clear Coverage at nebraskablue.com/clearcoverage.

More information can be found on BCBSNE’s provider site, nebraskablue.com/providers.

* Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

Blue Cross^®, Blue Shield^® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.