Medicare sequestration also suspended through March 31
This article is for the acute care and mental health hospitals caring for our members
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:
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.
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 |
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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 |
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Skilled nursing facility, rehabilitation, and long-term acute care hospitals | Notification only required (Updated January 13, 2021) |
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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. |
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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. |
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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 |
To request an authorization for |
Then |
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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 |
Behavioral health |
Call 1-800-524-4010 or fax 1-888-641-5199 |
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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