BCBSMA Utilization Management Changes for PPO and EPO Members

Blue Cross Blue Shield of Massachusetts is expanding utilization management to certain services for Commercial EPO and PPO Members.

PPO & EPO requirement changes:

Effective June 1, 2022:

The changes listed below apply to certain services that are covered by our members’ medical benefits.

Prior authorization for commercial EPO, PPO members

The following services will have an authorization requirement as of June 1, 2022. We will begin accepting authorizations at least 30 days in advance of the requirement date. Members having these services will require an approved authorization for coverage for dates of service on or after June 1, 2022.

Service	Applies to	Provider can request authorization
Continuous glucose monitors (Codes: A9277, K0553, S1036)	Commercial EPO and PPO	By calling the Pre-Authorization number on the back of the member’s card. Remember: Authorization is required on an annual basis.
Spine surgeries using InterQual SmartSheets for: Anterior Cervical Discectomy and Fusion (ACDF) Discectomy, Percutaneous, Lumbar Fusion (with Laminectomy), Cervical Fusion (with Laminectomy), Lumbar Fusion (with Laminectomy), Thoracic Fusion, Cervical Spine Fusion, Lumbar Spine Fusion, Thoracic Spine Hemilaminectomy (Laminotomy) +/- Discectomy, Cervical Hemilaminectomy (Laminotomy) +/- Discectomy, Lumbar Laminectomy (with Fusion), Cervical Laminectomy (with Fusion), Lumbar Laminectomy (with Fusion), Thoracic Laminectomy, Cervical Laminectomy, Lumbar Laminectomy, Thoracic	Commercial EPO and PPO	By calling the Pre-Authorization number on the back of the member’s card.
Other services	Commercial EPO and PPO	By calling the Pre-Authorization number on the back of the member’s card.

Applies to these services:

Authorization is required for these services for dates of service on or after June 1, 2022.
We will accept prior authorization requests starting on May 1, 2022.

How to request prior authorization:

Providers can contact the authorization area by calling 1-800-676-BLUE.

Please note that:

As always, we recommend checking benefits and eligibility to determine the member’s benefits and any authorization requirements.

All services must continue to meet medical necessity criteria. We will only provide reimbursement for services that meet these requirements and for which a prior authorization has been obtained.

After June 1, 2022, providers will be able to use the Medical Policy Router to search for Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems requirements (Medical Policy 107).

After June 1, 2022, providers will be able to use the Medical Policy Router to search for Outpatient Prior Authorization Code List (Medical Policy 072)

If you have additional questions regarding this latest news article, you can contact your BCBSKS provider consultant/representative.