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Medicare Advantage PPO

Copay and/or Coinsurance Based Plan

Listed below are the UM requirements in accordance with the terms of your Medicare Advantage PPO provider agreement. If a service is not listed below, there was not a contractual obligation identified; however, this page is designed to provide general guidelines for this line of business. Benefits vary according to the terms of the member contract. Check Availity for your member's specific guidelines.  

Please access Medical Policies (Medical Coverage Guidelines) for supporting information regarding the criteria used in determining coverage for payment purposes. All services must meet the definition of medical necessity as outlined in the Member's benefit contract. Although a service may not require an authorization it is still required to meet the definition of medical necessity and is subject to medical review pre-service, post-service or concurrently.

Service Contractual Obligation
Advanced Imaging
(CT scans, MRIs/MRAs, PET scans, nuclear medicine)
Authorizations are required and should be requested from NIA for CT scans, MRAs, MRIs and cardiovascular office and outpatient procedures. Refer to the NIA section for additional details.
Behavioral Health Services Inpatient and partial hospitalization: Certification is required.

Submit certifications electronically through Availity or contact New Directions Behavioral Health using Blue Express, our automated phone system.

Intensive outpatient and outpatient: Prior authorization is not required.

Note: Certification should occur within 24 hours of admission. Planned admissions- five business days prior to date of service.

Chiropractic

Authorization required for manual spinal manipulation codes prior to patient's sixth visit.

To submit authorization requests, please complete the enclosed Certificate of Medical Necessity (CMN) for Chiropractic Services form for your Medicare members and fax it to Florida Blue at (877) 219-9448.  To access additional CMS for Chiropractic Services forms, please visit Florida Blue's Medical Coverage Guidelines (Medical Policies) site at http://mcgs.bcbsfl.com.  Under the "What's New" section select "Services Requiring Certificates of Medical Necessity" to find the Chiropractic CMN.

Inpatient
(acute, psych, substance and LTAC)
  • Certification required for acute care hospitals, SNFs, and LTAC.
  • Submit authorization requests electronically through Availity or contact New Directions Behavioral Health using Blue Express, our automated phone system.
  • Certification is required for acute rehabilitation, however, additional steps are needed; contact our UM department.

Note: Certification should occur within 24 hours of admission. Certification for planned admissions should occur five business days prior to the date of service.

Laboratory

Quest Diagnostics and Dermpath Diagnostics are Florida Blue's preferred laboratory providers. The preferred lab for anatomical pathology services in Florida is AmeriPath. Services obtained at other facilities result in higher out-of-pocket cost for the member.

To view a list of laboratory services permitted in the physician’s office, access the In-Office Laboratory Services list. 

Outpatient Hospital Services
(including 23 hour observation care)
Notification is required for observation status admissions and all status changes from observation to inpatient.  Other outpatient services do not require authorization or notification.
Pharmacy
(provider administered)
Benefits vary by member contract and may contain medical cost share. This information can be found in Availity.
  • Member medical cost share exists for covered Medicare B care drugs administered in the office, which is 20 percent coinsurance.
  • Refer to the Medication Guide to determine drugs that require prior authorization.
  • PADP applies
  • Hemophilia program – managed by Caremark
  • Self-administered drugs may not be covered in the office except those used in the treatment of diabetes, cancer, conditions requiring immediate stabilization (e.g., anaphylaxis), or in the administration of dialysis which are covered. Refer to the Medication Guide for Medicare eligibles or a listing of drugs classified as self-administered.
  • Refer to the Pharmacy section for additional pharmacy program details.
  • For some Medicare Advantage PPO plans, self-administered drugs are not covered in the office. Refer to the Medicare Medication Guide.
Pharmacy
(self-administered)
Refer to the Medication Guide to determine drugs that require prior authorization
  • Hemophilia program – managed by Caremark
  • Refer to the Medicare Guide of Medicare eligibles for drugs covered under this plan.
  • Some self-administered drugs require prior authorization as identified in the Medication Guide for Medicare eligibles.
  • Refer to the Pharmacy section for additional pharmacy program details.
  • Click here for information regarding differences between Part B and Part D.
Skilled Nursing Facility (SNF) Participating facilities are required to notify our UM department of member admissions to SNFs before close of business of the day following the admission.

Florida Blue Care Coordinators review the SNF admission, either onsite or telephonically, and will collaborate with the facility staff to assist in identifying coverage options available for members through focused condition, discharge planning and ancillary services as needed.

The voluntary Select Medication Program is available to participating SNFs with access to select high-cost medication through Ambient Healthcare and Coram Infusion Specialty for members admitted for sub-acute care. Refer to the SNF program section for specific details.

Surgical Procedures
Authorization, certification, or notification is not required.

Potentially cosmetic, plastic or reconstructive surgery is subject to medical necessity review.

Transplant Services
(excluding office visit)
Prior authorization is required for transplant care and the facility performing the services must meet specific CMS criteria.
2/26/2014
The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

Refer to the References section to view all applicable copyrights, registered trademarks, service marks, and/or references. Acronyms are also defined in the References section.

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