MyBasic BlueSelect-BlueSelect

MyBasic BlueSelect - BlueSelect

Copay and/or Deductible & Coinsurance Based • Limited Benefit Plans

Listed below are the UM requirements in accordance with the terms of your BlueSelect 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.

Authorization, certification or notification is required for the services below. The terms of the member contract can be accessed via Availity and will determine coverage of the service.

If a participating provider fails to follow the required UM procedures, then BCBSF may deny payment for such services, and the participating provider may not bill the member for such services.

Compliance with BCBSF's UM programs includes, but is not limited to, the following:

Obtaining authorizations and/or certifications and providing applicable notification as may be set forth in this Manual
Providing clinical information when request
Identifying your contact person who will provide the member's medical information to the BCBSF UM onsite or telephonic nurse reviewer
Permitting access to the members' medical information
Including the BCBSF UM nurse in discharge planning discussions and meetings
Providing a plan of treatment and progress notes as required

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 necessity 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. Note: Maternity ultrasounds only require authorization when utilization limits are exceeded. Refer to the Medical Policies (Medical Coverage Guidelines) for limits.
Behavioral Health Services	Inpatient: All inpatient psychiatric and substance abuse admissions require authorizations and must be coordinated with New Directions Behavioral Health by the admitting facility. Outpatient: Behavioral health services are managed through an exclusive arrangement through New Directions. Contact New Directions for an initial outpatient authorization. Partial hospitalization, IOP, and substance abuse rehabilitation: Requires authorization and must be coordinated through New Directions.
Durable Medical Equipment (DME) and Medical Supplies (MS)	Authorization is required for all non-office based DME and MS needs provided by providers participating in the CareCentrix network. For these providers, all authorizations are to be requested through CareCentrix, BCBSF’s statewide provider for these services. Authorization requests from CareCentrix participating providers or physicians/providers referring to the CareCentrix network can be submitted by phone at 877-561-9910, or online through the CareCentrix web portal at https://www.carecentrixportal.com. Authorizations should be submitted five working days prior to the date needed or within 24 business hours of the physician’s order. Payment will be denied if authorization is not obtained. If extenuating circumstances exist that delay this process, the provider should advise CareCentix by calling 877-561-9910. For DME or MS items accessed through CareCentrix, CareCentrix will arrange for services to be rendered by one of its participating providers or will arrange for an out-of-network provider to provide the service should an in-network choice be unavailable. (On this rare occasion, the member’s claim will be processed with the in-network benefit.). DME or MS supplied by a provider that does not participate in CareCentrix network may not require prior authorization, but are eligible for a VPCR for a contingent covered service determination for equipment and supplies. However, final covered service(s) determination will be made when the claim is processed by BCBSF. For providers NOT participating in the CareCentrix network that require authorization for specific equipment, please contact BCBSF directly. Submit authorization requests electronically through Availity at www.availity.com or contact BCBSF using Blue Express, our automated phone system at (800) 397-7337. For physician/provider offices or any DME/Medical Supply provider that does not participate in CareCentrix network, the BCBSF website contains Medical Policies (Medical Coverage Guidelines) showing requirements for specific DME/Medical Supplies. Please review the specific Medical Policies (Medical Coverage Guidelines) before providing equipment or a supply. DME or medical supplies that exceed the quantity limitations in the Medical Policies (Medical Coverage Guidelines) are subject to prior authorization. NOTE: Non-custom equipment or medical supplies dispensed by a physician/provider office as a result of treatment received by the member in that office (e.g. crutches, canes, splints, walkers, etc.) can continue to be supplied by the office without the need to work through CareCentrix. All custom items MUST be requested through CareCentrix. Equipment or medical supplies dispensed by physician/provider offices are subject to BCBSF authorization requirements. (See "Office-Based Equipment/Supply Authorization Requirements" and "Office-Based Equipment/Supply Standing Authorizations" requirements below). Office-Based Equipment/Supply Authorization Requirements If necessary, authorization requests should be initiated electronically through Availity. If you receive a message that indicates medical review, contact our UM department. Requests should be submitted five working days prior to the date needed or within 24 business hours of the physician’s order. Payment will be denied if authorization is not obtained. If extenuating circumstances exist that delayed this process, the provider should advise our UM department. Office-Based Equipment/Supply Standing Authorizations Some DME and MS do not require a prior authorization and are considered to have a standing authorization for approval based on medical appropriateness of a BlueSelect member’s condition. Refer to the BlueSelect and Health Options DME section for a list of those items. Any items not included in this standing order section are subject to a prior authorization. In addition, refer to BCBSF’s Medical Policies (Medical Coverage Guidelines) for specific requests. DME or medical supplies that exceed the quantity limitations in the Medical Policies (Medical Coverage Guidelines) are subject to prior authorization.
Home Health (HH)/Home Infusion (HI)	Authorization requests from CareCentrix participating providers or physicians/providers referring to the CareCentrix network can be submitted by phone at 877-561-9910, or online through the CareCentrix web portal at https://www.carecentrixportal.com. Authorizations should be submitted five working days prior to the date needed or within 24 business hours of the physician’s order. Payment will be denied if authorization is not obtained. If extenuating circumstances exist that delay this process, the provider should advise CareCentix by calling 877-561-9910. For HH or HI items accessed through CareCentrix, CareCentrix will arrange for services to be rendered by one of its participating providers or will arrange for an out-of-network provider to provide the service should an in-network choice be unavailable. (On this rare occasion, the member’s claim will be processed with the in-network benefit.). For HH or HI supplied by a provider that does not participate in CareCentrix network, the BCBSF website contains Medical Policies (Medical Coverage Guidelines) showing requirements for specific HH/HI services. Please review the specific Medical Policies (Medical Coverage Guidelines) before providing HH/HI services. HH/HI services exceeding the quantity limitations in the Medical Policies (Medical Coverage Guidelines) are subject to prior authorization. For providers NOT participating in the CareCentrix network that require authorization for specific equipment, please contact BCBSF directly. Submit authorization requests electronically through Availity at www.availity.com or contact BCBSF using Blue Express, our automated phone system at (800) 397-7337.
Hospice	Notification required Submit notifications electronically through Availity or contact BCBSF using Blue Express, our automated phone system. Penalty: If timely notification is not made by a facility of an inpatient admission or if no notification is made, a financial penalty may be imposed of 20 percent of the total claim for an episode of care that would have otherwise been due to the inpatient facility under the Agreement then in effect if provider notification had been provided (regardless of payment methodology defined with the provider Agreement) up to a maximum of $500, for each BlueSelect member's inpatient claim received without a notification.
Inpatient (Acute, Psych, Substance and LTAC)	Notification required Submit notifications electronically through Availity or contact New Directions Behavioral Health using Blue Express, our automated phone system. Planned services: Notifications should be submitted five working days prior to the date of service. Emergency/Urgent inpatient services: Notification of the admission should be received as soon as possible but no later than the end of the next business day. For changes from outpatient to inpatient status, an inpatient notification must be made at the time the member is admitted. Penalty: If timely notification is not made by a facility of an inpatient admission or if no notification is made, a financial penalty may be imposed of 20 percent of the total claim for an episode of care that would have otherwise been due to the inpatient facility under the Agreement then in effect if provider notification had been provided (regardless of payment methodology defined within the provider Agreement) up to a maximum of $500, for each BlueSelect member's inpatient claim received without a notification. Note: Newborn admissions require separate authorization from mother if either baby stays after mother is discharged, admission will be billed with DRG 789-793, or if mother is not insured through BCBSF.
Laboratory	Laboratory services are managed under exclusive arrangement with Quest Diagnostics. To view a list of laboratory services permitted in the physician's office, see our In-Office Laboratory Services list.
Orthotics & Prosthetics (O&P)	Authorization is required for all non-office based O&P needs provided by providers participating in the CareCentrix network. For these providers, all authorizations are to be requested through CareCentrix, BCBSF’s statewide provider for these services. Authorization requests from CareCentrix participating providers or physicians/providers referring to the CareCentrix network can be submitted by phone at 877-561-9910, or online through the CareCentrix web portal at https://www.carecentrixportal.com. Authorizations should be submitted five working days prior to the date needed or within 24 business hours of the physician’s order. Payment will be denied if authorization is not obtained. If extenuating circumstances exist that delay this process, the provider should advise CareCentix by calling 877-561-9910. For O&P items accessed through CareCentrix, CareCentrix will arrange for services to be rendered by one of its participating providers or will arrange for an out-of-network provider to provide the service should an in-network choice be unavailable. (On this rare occasion, the member’s claim will be processed with the in-network benefit.). O&P supplied by a provider that does not participate in CareCentrix network may not require prior authorization, but are eligible for a VPCR for a contingent covered service determination for equipment and supplies. However, final covered service(s) determination will be made when the claim is processed by BCBSF. For physician/provider offices or any O&P provider that does not participate in CareCentrix network, the BCBSF website contains Medical Policies (Medical Coverage Guidelines) showing requirements for specific O&P services. Please review the specific Medical Policies (Medical Coverage Guidelines) before providing equipment or a supply. O&P that exceed the quantity limitations in the Medical Policies (Medical Coverage Guidelines) are subject to prior authorization. NOTE: Non-custom orthotics/prosthetics dispensed by a physician/provider office as a result of treatment received by the member in that office can continue to be supplied by the office without the need to work through CareCentrix. All custom items MUST be requested through CareCentrix. O&P dispensed by physician/provider offices are subject to BCBSF authorization requirements. (See "Office-Based Equipment/Supply Authorization Requirements" and "Office-Based Equipment/Supply Standing Authorizations" requirements below). Office-Based Equipment/Supply Authorization Requirements If necessary, authorization requests should be initiated electronically through Availity. If you receive a message that indicates medical review, contact our UM department. Requests should be submitted five working days prior to the date needed or within 24 business hours of the physician’s order. Payment will be denied if authorization is not obtained. If extenuating circumstances exist that delayed this process, the provider should advise our UM department. Office-Based Equipment/Supply Standing Authorizations Some O&P does not require a prior authorization and are considered to have a standing authorization for approval based on medical appropriateness of a BlueSelect member’s condition. Refer to the BlueSelect and Health Options DME section for a list of those items. Any items not included in this standing order section are subject to a prior authorization. In addition, refer to BCBSF’s Medical Policies (Medical Coverage Guidelines) for specific requests. O&P that exceed the quantity limitations in the Medical Policies (Medical Coverage Guidelines) are subject to prior authorization.
Pharmacy (Provider Administered)	Benefits vary by member contract and may contain medical cost share. This information can be found in Availity. Refer to the BlueSelect Medication Guide to determine drugs that require prior authorization. PADP applies 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 BlueSelect Medication Guide for a listing of drugs classified as self-administered. Refer to the Pharmacy section for additional pharmacy program details.
Pharmacy (Self-Administered)	Benefits vary by member contract. This information is found in Availity. Refer to the Medication Guide to determine drugs that require prior authorization Hemophilia program - manage by Caremark Refer to the BlueSelect Medication Guide for drugs covered under this plan. The BlueSelect Exception Request Form is available to request exceptions to this program. Note: Self-administered specialty drugs, as designated in the Medication Guide, may provide a lower out-of-pocket cost for some BlueSelect plans if obtained from our preferred specialty pharmacy Caremark.
Skilled Nursing Facility (SNF)	Notification required Submit notifications electronically through Availity or contact BCBSF using Blue Express, our automated phone system. Penalty: If timely notification is not made by a facility of an inpatient admission or if no notification is made, a financial penalty may be imposed of 20 percent of the total claim for an episode of care that would have otherwise been due to the inpatient facility under the Agreement then in effect if provider notification had been provided (regardless of payment methodology defined within the provider Agreement) up to a maximum of $500, for each BlueSelect member's inpatient claim received without a notification.
Surgical Procedures	Authorization required Submit authorization requests electronically through Availity or contact BCBSF using Blue Express, our automated phone system. Potentially cosmetic, plastic, or reconstructive surgery is subject to medical necessity review.
Transplant Services (excluding office visit)	Authorization required Submit authorization requests electronically through Availity or contact BCBSF using Blue Express, our automated phone system.