This article is for providers who use Authorization Manager for musculoskeletal services
Thank you for using Authorization Manager to submit your requests for musculoskeletal services. Here are some tips to help you avoid unnecessary delays with your submissions.
InterQual criteria
You must select the applicable InterQual® criteria in each section of your request. In the below example, a specific diagnosis is required to meet the criteria for a hip replacement. However, since the diagnosis noted is “none of the above,” the request will pend for additional clinical information to confirm that the member’s diagnosis supports the need for the procedure.
If you have questions about which category a diagnosis falls into, please email us at MSKInterqual@bcbsma.com.
Level of care requests
Total joint replacement surgery for hips or knees is generally considered a SDC (surgical day center) outpatient procedure. In some situations, an inpatient request may be appropriate if there are comorbidities that support the need for an inpatient level of care.
If your request does not indicate any comorbidities that support the need for inpatient surgery, it will pend for secondary medical review. Please consider whether the procedure can be done at the outpatient level of care. If any complications or changes in the member’s status arise after you’ve obtained an authorization, you may fax us a request to change the level of care.
See the example scenario below where there are no comorbidities selected, meaning the request will pend.
We’re here to help
- If you need help with or have questions about Authorization Manager, email us at HMMAuthorizationManager@bcbsma.com
- For clinical inquiries on InterQual®, email us at MSKInterqual@bcbsma.com
More resources
- Authorization Manager Provider Central page, which contains helpful tips, guides, and video demonstrations
- Authorization Manager User Guide
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