Effective September 1, 2011, the following procedures will apply when
requesting precertification through the NaviNet? web portal or the Provider
Automated System through 1-800-ASK-BLUE:
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Pain management providers. For precertification requests for pain
management procedures (i.e., paravertebral facet joint, transforaminal
epidural, and epidural injections), new clinical questions will be added to
evaluate medical necessity based on medical policy.
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Durable medical equipment (DME) providers. For precertification requests
for CPAP and BiPAP machines, new clinical questions will be added to evaluate
medical necessity based on medical policy.
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Home health providers. We will begin reviewing all precertification
requests for occupational and physical therapy services in the home beyond the
initial 60 days by applying InterQualR criteria. In addition, we will begin
reviewing precertified speech therapy services in the home beyond 60 days based
on medical necessity.
We strongly advise reviewing applicable medical policies in advance of
requesting precertification so you are prepared to provide the necessary
information. Medical policies are available on our website at www.ibx.com/medpolicy. Select Accept and Go to
Medical Policy Online, and type the name or number of a policy into the
Search box.
If you have any questions about these updated procedures, call 1-800-ASK-BLUE.
Reminder: Changes to precertification requirements effective September 1
As previously communicated, we will implement important changes to the list of
services and drugs that require precertification effective for dates of service
on or after September 1, 2011. Please refer to the article in the June edition
of Partners in Health Update for a complete list of changes to
precertification requirements.
As we proceed through this transition, it is very important for providers to
use NaviNet or the most current precertification requirements lists to verify
member-specific requirements. The updated lists are available online at www.ibx.com/providers/preapproval
Failure to obtain precertification for any of the services or drugs that
require it may result in a reduction in payment or nonpayment for the services
not precertified.
Note: These new precertification requirements will apply to commercial members
for dates of service on or after September 1, 2011; Medicare Advantage HMO and
PPO members will transition for dates of service on or after January 1, 2012.