For most plans, we require notification (not prior authorization) within 72 hours of admission for the initial 72 hours.

The facility must call the number on the back of the member’s ID card to notify us of the admission. If the member does not have their ID card, call 1-800-524-4010.

Federal Employee Program (FEP)

Precertification is required for acute inpatient care. If we don’t receive precertification within 48 hours of the admission, the member will have to pay a $500 penalty. To request precertification:

• Call 1-800-524-4010.
• Fax the Behavioral Health - Level of Care Request Form to us at the number listed on the cover sheet.

Note: FEP members with the Basic Option or FEP Blue Focus plan can only use providers who participate in our PPO networks.

Intermediate services may include acute residential treatment (sub-acute care), partial hospitalization programs, intensive community-based treatments (for children and adolescents), and intensive outpatient programs.

All authorizations for intermediate services are based on the medical necessity of services.

Outpatient medical oncology services and supportive care medications as noted in our medical policies:

• Quality Care Cancer Program (Medical Oncology) (099)
• Supportive Care Treatments for Patients with Cancer (105)

Radiation oncology services as noted in our medical policies:

• Quality Care Cancer Program Radiation Oncology Services Policy (937) 
• Quality Care Cancer Program (Radiation Oncology) (938)  

Ordering providers will request authorization with Carelon in one of three ways:

1. Through a direct link on this site (no additional registration is required). In the eTools tab, go to Carelon. Click the Go Now button.
2. Go directly to the Carelon ProviderPortal (registration is required) at www.providerportal.com.
   Note: If you’ve already registered for the Carelon ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won’t need to register again.
3. Call Carelon’s Contact Center at 1-866-745-1783
   • Available Monday through Friday, 8 a.m. – 6 p.m. If you leave a voicemail after these hours, Carelon will respond the next business day.

Medical oncology services

Required information:

• Member first, last name and date of birth
• Ordering provider’s first and last name
• Dispensing provider name
• Place of service

Most order request also may require:

• Clinical details
  • Patient height and weight
  • Diagnosis
  • Cancer type
  • Pathology and stage
• Chemotherapy regimen
• Biomarkers and tumor characteristics
• Line of treatment

For order entry worksheets and checklists, click here.

Radiation oncology services

Required information:

• Member first, last name and date of birth
• Ordering provider’s first and last name
• Primary cancer treatment being requested (for example, brachytherapy, IMRT, proton beam, etc.)
• Patient diagnosis
• Name and location of facility where treatment will be administered

Clinical data required:

• Pre-Exam Questions (PEQ):
  • Patient’s height and weight
  • T, N, M status or stage of cancer
• Cancer histology
• Performance status, either Karnofsky or ECOG
• Treatment goal, total dose, and number of fractions
• For some situations, plan comparison with 3D or IMRT is required. This information is available on Carelon’s radiation therapy website.

After entering and reviewing your request, you’ll receive a summary. Approved orders will indicate “Authorized” and will include an “Order ID.” You’ll also see a summary of codes and disease information.

To avoid a denied claim, servicing providers should use the Carelon's ProviderPortal to verify that an authorization is in place before the service is performed.

Many, but not all, members in these plans need an authorization for chiropractic services. Please check benefits and eligibility to determine if authorization is required.

Use ConnectCenter to see if the member requires authorization.

Go to Verification>New Eligibility Inquiry and complete required fields. Click Submit.

Scroll to view the response. Under Eligibility, look for Chiropractic. Authorization information appears in the fields under Message and Auth/Cert Required. If authorization is required, you'll see a message indicating the authorization is required for visits 13 and beyond.

If authorization is not required, you'll see a message like the one below. This message may appear if the member has a 12 visit benefit limit for chiropractic services.

Request authorization before the member's 13th visit. You can do this using WholeHealth Living’s web-based Rapid Response System.

Authorization requests must be submitted within seven days (+/-) from the date of the member’s 13th visit.

It’s helpful to have the following information ready to enter into the Rapid Response System (web or phone-based).

• The member’s ID number (prefix and suffix are not required) and date of birth.
• The injury mechanism (auto accident or work-related injury) or the presence of other insurance (if the other health insurance is primary and coordination of benefits applies).
• The member’s score from the Patient-specific Functional Scale (leave blank if member refuses to answer questions). The Patient-specific Functional Scale is available in English, Spanish, and Portuguese.
• Primary, secondary, and/or tertiary diagnosis codes.

You should also have the member’s medical record available since you will be asked multiple questions about the member’s diagnosis(es), medical history, and treatment plan.

Please refer to the Chiropractic Care Plan Authorization Request Form in the Appendix of the Chiropractic Services Authorization Program Guide for a complete list of the questions you will be asked to enter into the RRS.

• Web browser compatibility: Works best with Internet Explorer 11.
• Communication preferences: To get messages from WholeHealth Living’s about your authorizations, you’ll need to set up your communication preference. Choose either email or fax. You can change your preferences at any time.
  • For email, we suggest using an email address that others in your office (who handle authorizations) can access because an email can only go to one email address. When an email goes out about an authorization that has posted to the site, the email will be directed to that preferred email address. Then, you’ll need to log in to get the details about your patient.
• Message center: Your message center is your inbox. There, you’ll be able to track messages WholeHealth Living posts about your authorizations, appeals, requests from WholeHealth Living’s Utilization Management Department, or if additional information is needed to complete your authorization request.

When a message is posted, you get an email. Please make sure your system is set up to receive emails from noreply@tivityhealth.com, so messages don’t go into your spam or junk folders.

If you receive an adverse determination and want to appeal the determination, you will have two options for reconsideration.

1. Peer to Peer Requests: To request a discussion of the outcome of a clinical review with the peer reviewer who made the determination, please complete and return the "Request for a Peer to Peer Discussion" section of the UM Department Request Form. You’ll find more details on this process in the Chiropractic Services Authorization Program Guide.


2. Appeal Requests: If you disagree with a medical necessity review outcome, you have the right to request an appeal. You’ll find more details on this process in the Chiropractic Services Authorization Program Guide.
   
   To request an appeal for a pre-service or concurrent case:
   
   • Please complete and return the UM Department Request Form. Be sure to fill out the "Provider request for a Reconsideration of a Medical Necessity Determination" section.
   
   To request an appeal for a retrospective case:
   
   • Please complete the UM Department Request Form and return it by fax or by mail using the address in your determination letter. Be sure to fill out the "Provider request for an Appeal of a Medical Necessity Determination" section.

Rapid Response System

WholeHealth Living’s dedicated support line: 1-866-656-6071

Chiropractic Services Authorization Program Guide

Frequently Asked Questions about the Program

UM Department Request Form

Patient-specific Functional Scales

English
Spanish
Portuguese

Payment Policy

Chiropractic 

To download the Chiropractic payment policy, log in and click Find a Payment Policy on the right side of your home page. Or, go to Office Resources>Policies & Guidelines>Payment Policies.

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

Refer to Carelon Genetic Testing Management Program CPT and HCPCS Codes medical policy 957.

Categories of tests that require prior authorization include, but may not be limited to:

• Genetic testing for hereditary risk of cardiac disease
• Genetic testing for hereditary cancer susceptibility
• Genetic testing for single-gene and multifactorial conditions
• Pharmacogenetic and thrombophilia genetic testing
• Reproductive carrier screening and prenatal diagnosis
• Solid and hematologic tumor and malignancy testing
• Whole exome and genome sequencing

Prior authorization is not required for genetic testing associated with organ transplantation.

For preimplantation genetic testing, we don’t require prior authorization with Carelon; however, you should continue to request prior authorization from Blue Cross Blue Shield of Massachusetts for biopsy of the embryo. Refer to our medical policy, Preimplantation Genetic Testing: 088.

Ordering physicians or clinicians must request authorization before the member receives the test (or before performing services). There are three ways to contact Carelon to request prior authorization:

1. Through a direct link on this site (no additional registration is required). In the eTools tab, go to Carelon. Click the Go Now button.
2. Go directly to the Carelon ProviderPortal (registration is required)
   • Go to www.providerportal.com
   Note: If you’ve already registered for the Carelon ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won’t need to register again.
3. Call Carelon’s Contact Center at 1-866-745-1783
   • Available Monday through Friday, 8 a.m. – 6 p.m. If you leave a voicemail after these hours, Carelon will respond the next business day.

Here’s some general information you may need to request the authorization. You can find checklists for specific tests on the Carelon genetic testing program site.

• Member’s first and last name, date of birth
• Summary of the patient’s clinical diagnosis
• Ordering provider’s first and last name
• Clinical summary from the genetic counseling appointment
• Test being requested and the name of the laboratory performing the test (you’ll be able to choose the test from a menu that includes branded panels, or you can manually enter it)
• Pedigree or summary of three-generation maternal and paternal family history
• Maternal and paternal ethnic background/race

Tips for entering the date of service for the test
The date of service is the estimated date that the laboratory is likely to begin the testing process.

It is not the date the sample is collected, unless the test is being performed on the same date the sample was collected.

The ordering provider may not know the exact date that a test will be performed. A reasonable estimate of one to three days in the future will cover the vast majority of genetic testing performed.

Once the ordering physician, clinician, or their office staff has entered the required information into the online authorization tool, you’ll get an immediate decision (in most cases). If Carelon needs more time to review the information, the system will indicate that it’s pending review. And, if Carelon needs more information for their review, you’ll get a request to submit additional information.

Please note: When you request prior authorization, it's for a specific genetic test. You aren't requesting prior authorization for the CPT code(s).

Approved requests

When your authorization is approved, Carelon ProviderPortal will indicate it’s "Authorized" in the Order Request Preview (see  in the example below) You’ll also find:

• The name of the approved test & CPT code(s)
• The units approved

Click here to see larger view.

Please be sure to:

Important: We recommend attaching a copy of the approved authorization to your lab requisition instead of using a pre-populated lab requisition form, such as the one in the example below. When you enter the test into Carelon’s ProviderPortal, you are requesting the individual test, not a panel, so the test authorized and the pre-populated form are not always a match.

Please note: When you request prior authorization, it's for a specific genetic test. You aren't requesting prior authorization for the CPT code(s).

When a specimen comes into your lab for genetic testing, before you analyze the specimen, please remember to verify:

• An approved authorization for the test. You can verify the authorization approval by going to the Carelon ProviderPortal.
• The CPT codes approved as part of that authorization. Next, you can give those codes to your billing department for your claim, so your claims will process smoothly.
  • Click "View Details" (See  in the example above) to see any CPT codes associated with the test that are approved.

We’re matching the approved CPT codes and unit amounts to the claim that the laboratory submits. If these fields don’t match, the claim will deny. To avoid a denied claim, we urge clinical and hospital laboratories to use the Carelon ProviderPortal to verify that an authorization is in place before the test is performed. We suggest sharing the authorization approval information (CPT codes and units) with your billing department.

We use Carelon clinical criteria to make medical necessity determinations. Refer to our medical policy 954 for links to Carelon’s criteria.

Blue Cross continues to maintain medical policies for the following:

1. Expanded Molecular Panel Testing of Cancers to Identify Targeted Therapies: 790, for which we will continue to maintain the criteria and Carelon will administer prior authorization decisions.
2. Preimplantation Genetic Testing: 088, for which the biopsy of the embryo will continue to require prior authorization directly from Blue Cross Blue Shield of Massachusetts, but the associated genetic testing does not require prior authorization if performed for preimplantation genetic diagnosis (as opposed to screening).
3. Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy): 797. We maintain the criteria, but prior authorization should be requested through Carelon.

Carelon offers information on its resource website. You’ll find:

• Program information & clinical guidelines
• Tutorials (on how to enter an authorization using the Carelon online tool)
• Worksheets to help your office prepare the information needed to enter the authorization request

To determine if a member has separate habilitation benefits, perform an eligibility inquiry in ConnectCenterConnectCenter using the Service Type, "Physical Therapy" or "Occupational Therapy." When the member has separate benefits, the Message column in your results will list Rehabilitation and Habilitation separately as shown in the screenshot below.

To request an initial authorization for habilitation services, the PCP or authorized specialist should call Clinical Intake at 1‑800-327-6716. We'll work with you to get an authorization for up to 26 PT/OT (combined) visits in the current calendar year.

To request an extension of an existing authorization, the PCP or authorized specialist should fax us a completed Habilitative Therapy Request Form for HMO Members.

If your patient could benefit from a collaborative approach, combining mental health and primary care, then Firefly Health and Carbon Health might be the solution. Both are national provider groups that offer virtual primary and mental health care to our members. Eligible members* can choose a virtual primary care provider associated with either group and get support from a virtual care team to manage their health. Both Firefly and Carbon work closely with mental health providers to give members a collaborative care experience.

*Firefly Health and Carbon Health are currently available to our members with commercial plans (HMO, PPO, and POS). These options will be available to Medicare Advantage and Federal Employee Plan members in the future.

The following groups offer mental health care in-person and virtually, as described below. The clinicians are generalists who provide therapy and medication management. They have an easy-to-use central intake service where members can log on and schedule appointments. These groups strive to schedule our members for their first appointment in a two- to three-day timeframe from the initial call.

The following groups offer innovative clinical care among a variety of specialized mental health conditions. Often, these subspecialty groups provide alternatives to residential treatment.

Many of our members have access to Learn to Live, a self-guided, 24/7 online support program based on Cognitive Behavioral Therapy (CBT). The program is intended to help manage social anxiety, depression, stress, anxiety, panic, insomnia, and moderate substance use. It is available in English and Spanish to members 13 and up on fully insured and self-insured accounts that offer this program.

For high technology radiology (HTR) services provided in the elective, outpatient setting, we require prior authorization for most commercial HMO/POS, PPO, and Medicare Advantage HMO and PPO. Carelon Medical Benefits Management (formerly AIM Specialty Health) administers this program on our behalf.

Requirements do not apply to Federal Employee Program members. In addition, prior authorization is not required for any member for HTR studies performed:

• In the emergency department
• As part of observation
• In an inpatient setting
• As part of an outpatient surgery

Copayments may apply
For some plans, a member may be responsible for a copayment for certain outpatient radiology studies. As always, check eligibility and benefits before rendering service to determine the member’s cost-share for HTR services.

Ordering clinicians should use eligibility and benefit technologies like ConnectCenter—available 24 hours a day, 7 days a week—to determine what’s required for each of their patients.

Perform your inquiry using the Service Type, MRI/CAT Scan.

Below is an example of ConnectCenter eligibility search results.

For these services, we require prior authorization for all commercial and Medicare Advantage members:

• Computed Tomagraphy (CT/CTA)
• Magnetic Resonance Imaging (MRI/MRA)
• Nuclear Cardiology Studies
• Breast MRI
• fMRI
• MRS
• Coronary CT/CTA
• CT/PET Fusion
• PET Scans
• Diagnostic and screening colonography

Ordering physicians or clinicians must request authorization before the member receives the test (or before performing services). There are three ways to contact Carelon to request prior authorization:

1. Through a direct link on this site (no additional registration is required). In the eTools tab, go to Carelon. Click the Go Now button.
2. Go directly to the Carelon ProviderPortal (registration is required)
   • Go to www.providerportal.com
   Note: If you’ve already registered for the Carelon ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won’t need to register again.
3. Call Carelon’s Contact Center at 1-866-745-1783
   • Available Monday through Friday, 8 a.m. – 6 p.m. If you leave a voicemail after these hours, Carelon will respond the next business day.

Registration is required for web access. When a new provider joins your group, please make sure that clinician is registered with Carelon.

If you are the contracted provider or facility performing the study:

• Register for Carelon as a servicing provider
• Use Carelon’s website to verify whether a prior authorization number has been issued for the member before rendering the service.

Prior authorization is valid for 60 days from the date issued. If the member does not receive the approved test within 60 days, the ordering provider will need to submit a new request.

You will need the following information to make your request:

• Member’s name, ID number, and date of birth
• Ordering provider’s name and address
• Name of imaging facility where the exam will be performed and the date of service
• Type of service (CPT code optional).
• Reason (indication) for the imaging procedure and/or CPT diagnosis code
• Medical records of pertinent previous studies (labs, X-rays, etc.) and treatments, including their duration. This information is critical to the decision-making. If not included, your request is likely to be denied.
• Member’s symptoms

If you are requesting multiple services, please attach medical necessity notes for each service requested. 

Carelon will issue a prior authorization number, or forward the case to a nurse or physician for review.  The physician reviewer may contact the ordering provider to discuss the case.  Ordering providers may also contact Carelon’s physician reviewer at any time during the process.

Carelon is delegated to conduct individual consideration for certain HTR modalities. Here’s more information about the appeals process for HTR services:

Landmark Health

For our Medicare Advantage members with multiple chronic conditions, we offer Landmark Health. Landmark’s providers—physicians, nurse practitioners, and physician assistants—go to patients’ homes of patients to help keep them well, and provide urgent care when needed. This service does not replace the care provided by the member’s PCP.

Hinge Health

We offer commercial members in fully insured accounts a program for chronic back and joint pain with Hinge Health. This program will also be offered to Medicare Advantage members starting on January 1, 2024.

Hinge’s pain management program helps adults proactively manage joint and muscle pain through a 12-week, coach-led, digital experience that aims to reduce anxiety and depression, improve strength and mobility, and introduce alternatives to surgery. Participants will continue to have access to all components of the Hinge Health Program, including coaching and/or facilitated social interaction and educational content for 12 months following their engagement in the Hinge Health Program.

We’ll identify eligible members based on claims history for qualified diagnosis codes. Members will then be able to enroll via the Hinge website.

Hinge’s program does not replace the physical therapy benefit for our members, and no claims will be submitted.

This program offers exercise therapy, not physical therapy.

Resource

Member website (commercial members): https://www.hingehealth.com/for/bcbsmafi/

Member website (Medicare Advantage members): https://www.hingehealth.com/for/bcbsmamedicare/

Vori Health

Members 18 and older* have access to virtual visits with Vori Health’s care team for back and joint pain. They are listed on our Find a Doctor & Estimate Costs tool as a Physical Medicine provider. A referral is needed for HMO members and the member’s cost for this virtual care provider depends on their plan.

After an initial telehealth visit, Vori’s care team will develop a treatment plan that may include:

• Physical therapy
• A reduction or change in medication
• Nutrition counseling
• Healthy lifestyle coaching
• Appointments with nurse practitioners or physician assistants as needed

*Commercial members, except Federal Employee Program and plans administered by Blue Benefits Administrators.

Resource

Member website: http://Vorihealth.com/bcbsma

Square Knot Health, for select Medicare Advantage members

We are partnering with Square Knot Health, an independent company focused on patients with advanced chronic kidney disease (Stage 4, 5, and end-stage kidney disease). This program supplements the care that our Medicare Advantage members receive from their existing doctors by educating, assessing, and mentoring them as they consider treatment options, including transplantation.

Resources

• News article: New chronic kidney disease program for Medicare Advantage members
• Blue Cross Member Medicare Options
• Square Knot Health

Through claims data and other analytics, we navigate members to these care solutions that help complement the care they’re already receiving from their health care providers. Members can learn more on our Diabetes page or call us at the Member Service number listed on their ID card.

As always, members can find doctors, specialists, and durable medical equipment providers (for diabetic equipment and supplies) using our Find a Doctor & Estimate Costs tool.

Livongo

• Livongo is a diabetes management program that helps adults with type 1 or 2 diabetes to take control of their condition and treatment by introducing a connected blood glucose meter, personalized analytics, and access to coaching, including certified diabetes educators.
• Available to self-insured accounts as an option.

Transform Diabetes Care

• Transform Diabetes Care supports adults with type 1 or type 2 diabetes with glucose and blood pressure monitoring, preventive screenings, medication optimization and adherence, and lifestyle and nutrition management.
• Support is offered through CVS Pharmacy, CVS MinuteClinic, and CVS HealthHUB locations, as well as remote options.
• Available through our pharmacy benefit manager as a standard benefit to self-insured accounts who use our pharmacy benefits.

Resource

•  Transform Diabetes Care member fact sheet

Virta Health

• Through a mobile app and a clinical support team, Virta Health helps members reverse their type 2 diabetes without surgery and achieve full remission without medication. They offer nutrition therapy, physician-led care, education, and coaching.
• Is available to qualified adult commercial HMO/POS and PPO members (does not apply to Federal Employee Program members). Eligible members need a smartphone to participate.

Resources

• Virta Health member website: virtahealth.com/join/bcbsma.
• Virta Health fact sheet for providers

Cost Share Assistance with PillarRx
Offers members savings on high-cost specialty medications through drug manufacturer coupon programs. (Self-insured accounts with 100+ subscribers can opt-in to this product; Fully-insured employers can opt-in with 51+ subscribers; it is a core benefit on merged market plans).

Drug Savings Review
The program uses pharmacy claims to help deliver prescription drug savings and medication optimization through proactive provider outreach (Standard benefit for self-insured accounts).

Pharmacy Advisor
Uses pharmacy claims and social determinants of health data to identify members at risk for non-adherence. Pharmacists provide counseling to members on their medications. (Standard benefit for self-insured accounts).

Medical Cost Avoidance
Analyzes pharmacy and medical claims, plus other data to identify gaps in care. Program engages members in individualized interventions to remind them of the importance of preventive screenings, vaccines, and helps prevent hospital readmissions. (Standard benefit for self-insured accounts).

This medication therapy management program is offered as a service to eligible Medicare Advantage members. It’s offered through pharmacy benefit manager CVS Caremark and Outcomes Inc.

REACH (Recovery, Education, and Access to Community Health)

This program is offered at no cost to our members, through our partnership with Carelon Behavioral Health. REACH is designed to help patients with mental health difficulties and/or substance use disorder by arranging care with health care providers to ensure patients feel supported when they leave the hospital. Learn more about REACH.

Maven

Maven Clinic offers virtual guidance and support to members and their families throughout the maternity journey*, including:

• Pregnancy
• Doula care
• Postpartum and infant care
• Lactation support
• Return-to-work coaching
• Miscarriage and loss
• Partner support

*The maternity journey includes during pregnancy and within the first three months postpartum; members who recently experienced a pregnancy or infant loss, and a partner of someone pregnant, recently postpartum, or who has recently experienced a pregnancy or infant loss.

What services do they offer?

• Coaching and education through telehealth consultations, and using video and instructional support
• 24/7 access on mobile devices
• Same-day appointments
  
• Online content, virtual classes, community forums
• Culturally diverse and conscious providers who speak multiple languages

Who is eligible?
Qualified commercial HMO/POS and PPO members (does not apply to Federal Employee Program members). The Maven maternity program is a core offering for fully insured employers with 51 or more employees. Self-insured accounts can pick from the maternity and newborn care program or offer additional programs that Maven offers in these areas: fertility and family building; parenting and pediatrics; and menopause.

Resource

Maven member website: https://www.mavenclinic.com/

Occupational therapy (OT) and physical therapy (PT) services are typically a combined benefit under a member's short-term rehabilitation therapy benefits. Authorization is required for members in the following plans:

• HMO
• POS
• Medicare HMO Blue

Reminder: Benefits and benefit limits may vary by account. As always, please check the member’s benefits and eligibility before rendering services.

When a patient needs physical or occupational therapy, the member’s primary care provider (PCP) or an authorized specialist is responsible for requesting initial authorization for combined PT/OT visits. (Note: For Medicare Advantage members, only the PCP may submit outpatient rehabilitation therapy authorization requests.)

To do this, the PCP or specialist will need to use a technology. Be sure that you enter the appropriate group PT/OT NPI number. If the member’s maximum visits have already been met for the authorization period, a message will be displayed.

When the request is made electronically, we will automatically approve the initial visits. All authorizations processed in the current authorization period will have the same end date as the initial authorization.

Technologies you can use to submit your request

• Authorization Manager. Follow the instructions in our Quick Tip and User Guide.
• Direct Connection.
  

No authorization is required for members of the Federal Employee Program. However, benefit limits apply for Physical Therapy, Occupational Therapy and Speech Therapy combined.

To learn the status of an authorization, you can:

1. Use an electronic technology like Authorization Manager.
2. Enroll in our Automated Fax-back Program to receive daily notices of all service approvals and denials entered into our medical management authorization system for your facility/practice. Enrolled providers receive a Daily Inpatient and Outpatient Notification Report via fax.

For all members except Medicare HMO Blue:

To make medical necessity decisions for initial authorization and extension requests, we use InterQual^® Criteria and our medical policies, as described in the subscriber certificate. Visit our InterQual Criteria() page for information about how to access these criteria.

For Medicare HMO Blue members:

We use Centers for Medicare & Medicaid Services (CMS) criteria. Please see the Medicare Benefit Policy Manual.

Before performing a service that requires an authorization, you should take these steps:

Step	Use an eTool like Authorization Manager or ConnectCenter to determine whether a referral or authorization is required for a specific service. Learn about our eTools. Once you’ve checked member benefits and eligibility, our Inpatient Only List can help you in making level of care determinations. Please also refer to our medical policies.  Inpatient Only List January 2024 (commercial members)
Step	Submit your authorization request (see submission tips below).
Step	Check the status of your authorization request. Use Authorization Manager. For instructions, download our User Guide. Receive notifications by fax by enrolling in our Automatic Fax-Back Program. This program is our automated fax process for faxing individual decision letters to enrolled providers. Once enrolled, you will receive a fax notification each time a member’s case is approved or denied in our system. To enroll in this program, please complete and return our Automatic Fax-Back Program: Request Form.
Step	Perform the service and submit the claim (after you’ve confirmed you have an authorization on file for the service).

Either the primary care provider or the designated specialist (with an open referral from the primary care provider, as applicable depending on the plan) can request authorization for outpatient services. If we have not provided approval for outpatient services that require authorization, the provider rendering the service is financially liable, unless the member has previously consented in writing to be billed.

We urge you to check on the status of your authorization requests electronically. If you have questions once you’ve taken this step, you may reach us at the phone and fax numbers indicated below.

Phone information

Fax information

Speech therapy services can sometimes be a combined benefit under an HMO/POS member’s short-term rehabilitation therapy benefits. For members of our Medicare HMO Blue Plan only, we require authorization for the initial 30 visits.

When a patient needs speech therapy, their primary care provider (PCP) or an authorized specialist is responsible for generating an auto-approved initial authorization for the first 30 visits, every 365 days.

To do this, the PCP or specialist will need to use a technology. If the member’s maximum visits have already been met for the 365-day authorization period, a message will be displayed.

Technologies you can use to submit your request

• Authorization Manager
• Direct Connection

No authorization is required for members of the Federal Employee Program. However, benefit limits apply for Physical Therapy, Occupational Therapy and Speech Therapy combined.

To learn the status of an authorization, you can:

1. Use an electronic technology like Authorization Manager.
2. Enroll in our Automated Fax-back Program to receive daily notices of all service approvals and denials entered into our medical management authorization system for your facility/practice. Enrolled providers receive a Daily Inpatient and Outpatient Notification Report via fax.

We use Centers for Medicare & Medicaid Services (CMS) criteria. Please refer to the Medicare Benefit Policy Manual.