Understanding Bcbs Medical Necessity Form Requirements

To submit a claim to BCBS, you'll need to complete a medical necessity form, which must be signed by a healthcare provider. This form is crucial for getting approved for services.

The form requires documentation of the patient's medical history, including any previous conditions or treatments. This information helps BCBS determine whether the requested services are medically necessary.

BCBS has specific requirements for the medical necessity form, including the need for a diagnosis code and a procedure code. These codes help identify the specific medical issue and the treatment being requested.

The form must also include a clear description of the proposed treatment and its expected outcomes. This ensures that BCBS understands the medical necessity of the requested services.

The authorization process is an essential step in ensuring that medical services are covered by your health insurance plan. Prior authorization is a pre-service medical necessity review that checks if a service or drug is medically necessary and covered under your plan.

Participating providers are responsible for obtaining prior authorization when required, and failure to do so can result in denied services or claims.

A prior authorization is not a guarantee of benefits or payment, and the terms of your plan control the available benefits.

To obtain prior authorization, you can use the eviCore Healthcare Web Portal, which is available 24/7, or call toll-free at 855-252-1117 between 7 a.m. and 7 p.m. Monday through Friday.

The following services require prior authorization through eviCore: Molecular and Genomic Tests, Musculoskeletal, Outpatient Advanced Radiology, Outpatient Medical Oncology, Outpatient Sleep, and Outpatient Specialty Drug.

Here are the steps to obtain prior authorization through eviCore:

Alternatively, you can use the AIM Specialty Health (AIM) ProviderPortal for pre-service reviews, which offers self-service, smart clinical algorithms, and in many instances, real-time determinations.

The services requiring prior authorization through AIM are: Molecular and Genomic Tests, Radiation Therapy, Advanced Imaging, Musculoskeletal, Sleep Studies, and Select Outpatient Procedures.

You can use the AIM ProviderPortal to submit the New Mexico Uniform Prior Authorization Form for services requiring prior authorization by AIM.

AIM Contact Information: Via Phone: (800) 859-5299, Online: through the AIM ProviderPortal.

Prior authorization is an essential step in ensuring that medical services are covered by your health insurance plan. It's a pre-service medical necessity review that checks if a service or drug is medically necessary and covered under your plan.

By following these steps, you can ensure that your medical services are covered and that you receive the necessary care.

Pre-service reviews are an essential part of the healthcare process, ensuring that services are covered under the health plan. These reviews are typically conducted before services are provided, and they help determine medical necessity.

There are several types of pre-service reviews, including prior authorization and Recommended Clinical Review (Predetermination). Prior authorization is required for services and drugs on specific lists, and failure to obtain approval may result in non-coverage and financial liability for the provider or member.

Recommended Clinical Review (Predetermination) is a process used by BCBSMT to make coverage decisions based on medical policy and group or member contracts. Providers can submit requests for this review, which will determine if the planned service meets approved medical policy criteria.

If a service is deemed not medically necessary, the provider and member will be notified, and they will have the opportunity to appeal the decision. The provider can also alter the financial liability of a service by informing the member of the potential denial through Advance Member Notification.

Here are some key facts about pre-service reviews:

Advance Member Notification is a crucial step in the pre-service review process. It's a way for providers to inform members about the financial implications of receiving a service before it's performed.

The member understands the financial implications of receiving the service through the Advance Member Notification process. This is a key benefit, as it allows them to make informed decisions about their care.

The participating provider can alter the financial liability of a service that would be denied as not medically necessary, experimental, investigational, or unproven. This is a great opportunity for providers to work with their members to find alternative solutions.

Here are the key benefits of Advance Member Notification:

Obtaining a predetermination review is a crucial step in ensuring that your services are covered by the insurance plan. You can submit a request for a Recommended Clinical Review (Predetermination) using the Certification for Admission Provider Interactive Form or the Healthy Montana Kids (HMK) - General Form.

This process allows BCBSMT to review your planned service for medical necessity before you provide it. The review will determine if the service meets approved medical policy, American Society of Addiction Medicine (ASAM) or MCG Care Guideline criteria.

You can submit a Recommended Clinical Review request for all services, including DME, Prosthetics or Orthopedic Devices. This review is optional, but it informs you and the member of situations where a service may not be covered based on medical necessity.

To submit a request, you can use the Recommended Clinical Review (Predetermination) Commercial General Interactive Form or the Recommended Clinical Review (Predetermination) Medicare Advantage Provider Interactive Form. The latter is specific to BCBSMT Medicare Advantage Medical benefits.

Here are some key forms to know:

By submitting a predetermination review, you can avoid potential denials and delays in payment. You'll also have the opportunity to appeal an adverse determination if the review determines the proposed service doesn't meet medical necessity.

Post-service reviews can be a critical part of the utilization management process, ensuring that services provided are medically necessary and covered under the member's benefit plan.

If a service required a prior authorization for a Medicare member, the claim will be denied with no post-service review. This means that providers should always check if prior authorization is required before rendering services.

Post-service reviews can include requesting medical records and reviewing claims for consistency with medical policies, other clinical guidelines, the provider agreement, coding and compensation policies, and accuracy of payment.

During a post-service utilization management review, the reviewer will examine the clinical documentation to determine whether the service was medically necessary and covered under the member's benefit plan.

A post-service review may ask for information that is not readily available, so providers should be prepared to provide additional documentation if requested.

Here are some key aspects of post-service reviews that providers should be aware of:

BCBSNM has contracted with AIM to provide certain utilization management prior authorization services for certain Commercial, Retail and ASO members and Blue Cross Community Centennial Members. Services requiring prior authorization through AIM include Molecular and Genomic Tests, Radiation Therapy, Advanced Imaging, Musculoskeletal, and Sleep Studies for specific member groups.

You can use AIM's ProviderPortal to request prior authorization and respond to post-service review requests. This portal offers self-service, smart clinical algorithms, and in many instances real-time determinations.

The AIM ProviderPortal allows you to check prior authorization status, increase payment certainty, and even receive faster pre-service decision turnaround times than post-service reviews. Medical records may or may not be needed for pre or post-service reviews using the AIM portal.

Services requiring prior authorization through AIM include:

AIM's ProviderPortal also allows you to submit the New Mexico Uniform Prior Authorization Form for services requiring prior authorization by AIM. To do this, simply check the "Submit New Mexico Uniform Prior Authorization Form" box and then click the "Upload Form" box to upload the completed form through the ProviderPortal.

You can contact AIM via phone at (800) 859-5299 or through the AIM ProviderPortal for any questions or concerns about the prior authorization process.