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COVID-19: Authorization requirements waived until March 31
January 8, 2021

Medicare sequestration also suspended through March 31

This article is for the acute care and mental health hospitals caring for our members

Updated January 13, 2021: Revised authorization requirements for skilled nursing facility, rehabilitation and long-term acute care hospitals. Please go to the COVID-19 Information for Providers page for the latest updates.

In September we announced that we would waive authorization requirements at inpatient acute care and mental health hospitals for dates of service through December 31, 2020.

Recognizing that hospitals continue to experience administrative resource issues due to COVID-19, we will continue to waive authorization requirements for inpatient acute care and mental health hospitals through March 31, 2021.

This extension applies to:

  • All inpatient acute care and mental health admissions, whether or not related to COVID-19
  • Prior authorization and concurrent reviews for inpatient admissions
  • Scheduled surgeries at inpatient acute care hospitals
  • All Blue Cross Blue Shield of Massachusetts products, except the Federal Employee Program (FEP). FEP follows Blue Cross Blue Shield Association referral and authorization guidelines. For more details, see fepblue.org.

Notification of admissions

Through dates of service up to and including March 31, 2021, inpatient acute care hospitals and mental health hospitals must notify us of inpatient admissions. Timely notification serves to facilitate care coordination, mobilize services to support transition of care, and ensure prompt claims processing. While this notification-only requirement is in place, we will not perform medical necessity reviews.

Starting with dates of service on or after April 1, 2021, authorization requirements will be reinstated. You will need to submit requests and supporting documentation for prior authorization at that time.

Authorization requirements by service and product

These authorization requirements are in effect for dates of service through March 31, 2021.

Network requirements
All prescheduled services and admissions, including home care services and skilled nursing admissions, are expected to be referred to in-network providers. Out-of-network requests for scheduled services will be reviewed on an individual case basis.

Definitions

Notification only required Does not require submission of clinical documentation for initial admission or concurrent review
Medical necessity review required Requires that the requesting provider submit clinical documentation in support of the request

Authorization requirements

Level of care or service Commercial HMO, Indemnity, and PPO Medicare Advantage FEP
Behavioral health – inpatient Notification only required Medical necessity review required
Behavioral health – acute residential treatment (partial hospitalization & intensive outpatient program) Medical necessity review required
Behavioral health – inpatient Notification only required Medical necessity review required
Pre-service inpatient
(for dates of service on or after April 1, 2021)
Medical necessity review required
Skilled nursing facility, rehabilitation, and long-term acute care hospitals Notification only required
(Updated January 13, 2021)
Previously approved elective surgeries To avoid duplication of cases and ineligibility issues due to changes in member coverage since the initial approval, prior authorizations will not be automatically extended into 2021.

If a previously approved service is being provided after December 31, 2020, please call our Clinical Intake Department at the appropriate number and we will initiate a new authorization request or update the existing one.

Previously approved
behavioral health testing (example: neuropsychological testing), IVF, DME
To avoid duplication of cases and ineligibility issues due to changes in member coverage since the initial approval, prior authorizations will not be automatically extended into 2021.

If a previously approved service is being provided after December 31, 2020, please call our Clinical Intake Department at the appropriate number and we will initiate a new authorization request or update the existing one.

For neuropsychological testing, new authorization requests will continue to have 365 days for the services to be completed. After that time, an authorization extension is required.

Vendor services (AIM) Effective January 1, 2021, AIM will resume standard processes and authorize services for 60 days for commercial services; this does not apply to FEP.
Home health care
Benefit limits still apply
Medical necessity review required HMO
Notification only required
PPO
No notification required
No notification required

Clinical Intake Department Phone Numbers

To request an authorization for

Then

Commercial members

Call 1-800-327-6716 or fax 1-888-282-0780

Medicare HMO and PPO members

Call 1-800-222-7620 or fax 1-800-447-2994

Federal Employee Program (FEP)

Contact your local plan. In Massachusetts, call 1-800-689-7219 or fax
1-888–282–1315

Behavioral health

Call 1-800-524-4010 or fax 1-888-641-5199

Medicare sequestration suspended through March 31, 2021

As part of the Consolidated Appropriations Act of 2021, Congress extended the suspension of the mandatory payment reductions known as “sequestration” through March 31, 2021. Beginning on April 1, 2021, sequestration will be reinstituted.

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