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New prior authorization system goes live for Medicare Advantage
February 11, 2020

This article is for providers caring for our Medicare Advantage members

Effective Monday, February 17, 2020, our new modernized utilization management system for Medicare Advantage members goes live. As we previously communicated, this will change the way that we will notify you of prior authorization review results for your Medicare Advantage patients. This new system will not:

  • change the way we notify you of review results for Medicare Part D prescription services or Medex®' members
  • impact referral and authorization submissions or inquiries via Online Services; those processes remain the same.

We plan to implement changes to prior authorization for our commercial and Federal Employee Program products at a later date. Until then, we will follow the current authorization processes for these members.

Maintenance for Online Services: Referrals and authorizations affected
From 7 p.m. Friday, February 14 until 7 p.m. Sunday, February 16, you will not be able to submit or check either referrals or authorizations. All other functionality will be available. You will be able to submit claims, access benefits and eligibility information, and submit faxes as usual. Pharmacy is not impacted.

How to access the new utilization management system Monday, February 17

  • Log in to Provider Central to access our new “Prior Authorization Management” system for Medicare Advantage members. Go to eTools>Prior Authorization Management.
    • From there you can access our video tutorial for how to use the system and our Prior Authorization Management Quick Start Guide.
  • You can continue to use Online Services to check authorization request status. For instructions, download our Online Services Quick Start Guide.

 Here is what to expect.

For Starting February 17
Requests pended for additional information We will still fax you a letter detailing the clinical information we need to complete the review.
Denials We will still call you and send a copy of the member’s denial letter via US mail.
What’s new:
You will be able to view the status of authorizations through our new utilization management system.
Requests for prior authorization and status Please continue to follow the current process to request prior authorization and status inquiries.
What’s new:
  • You will be required to enter a diagnosis and an end date with your request when submitting electronic authorization requests online for physical therapy (PT), occupational therapy (OT), and speech services.
  • You’ll be able to view status of authorizations through our new utilization management system.
Approvals We will continue to send an approval letter via US mail.
What’s new:
  • If you are participating in the Auto Fax-back Program, we’ll fax approvals of individual cases to your office.
  • You’ll be able to check approvals through our new utilization management system.
  • The number of approvable physical therapy visits will increase to 12 before requiring a medical necessity review.
  • The number of approvable occupational therapy visits will increase to 12 before requiring a medical necessity review.
  • All new authorization and referral case numbers will begin with the number 6.
The automated
fax-back program		 What’s new:
We will no longer send an evening fax summary of all approvals, denials, and requests for clinical information. The new functions noted above will replace this program.

Questions?

If you have any questions, please call Network Management and Credentialing Services at 1-800-316-BLUE (2583). As always, thank you for the care you provide to your patients—our members.

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