Preauthorization

Access the list of services, procedures and medical policies requiring authorization (certification) prior to providing the service.

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View the Preauthorization List

All investigative denials will be considered provider liability, even if a preauthorization is done and denied as being investigative. 

Per our BCBSNE Provider Procedures, a provider may hold a member financially liable for a medical necessity or investigative denial only if:

• The provider has advised the member – prior to services being provided – that he or she may be financially liable for the services provided
• The provider must give the member an estimate of financial liability

For a situation where a patient requests services considered not medically necessary and/or investigative and agrees in writing to be responsible for the non-covered charges, the provider must file a paper claim with the signed patient waiver. If a claim is filed without a waiver and the claim is denied as provider liability (but a waiver was signed prior to the claim being filed), a provider may submit a reconsideration with the waiver.

If a written agreement cannot be obtained, verbal notification may be given by the provider. The verbal notification must be documented in the patient’s medical records at the time the notification is given, and evidence provided to BCBSNE. For all other balances, the provider agrees not to bill or collect any amount from the member.

The most efficient way to expedite a preauthorization is to submit your request online. You can also fax your request with medical rationale.

Submit a Preauthorization Online (NaviNet)

Please refer to the provider procedure below that outlines the Medicare Advantage (MA) preauthorization requirements.

MA Prior Authorization and Precertification Requirements

The Musculoskeletal (MSK) program is designed to improve quality and manage the utilization of Interventional Pain Management (IPM) procedures and musculoskeletal surgeries. 

• Musculoskeletal surgeries are a leading cost of health care spending trends.
• Variations in member care exist across all areas of surgery (care prior to surgery, type of surgery, surgical techniques and tools and post-op care)
• Diagnostic imaging advancements have increased diagnoses and surgical intervention aligning with these diagnoses rather than member symptoms.
• Medical device companies marketing directly to consumers.
• Surgeries are occurring too soon leading to the need for additional or revision surgeries.

Outpatient IPM:

A separate prior authorization number is required for each procedure ordered. A series of injections will not be approved.

• Spinal Epidural Injections 
• Paravertebral Facet Joint Injections or Blocks
• Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis) 

Outpatient and Inpatient Spine Surgeries:

•  Lumbar Microdiscectomy
• Lumbar Decompression (include laminotomy, laminectomy, facetectomy, foraminotomy)
• Lumbar Spine Fusion (Arthrodesis) With or Without Decompression – Single and Multiple Levels
• Lumbar Artificial Disc Replacement -Single and Multiple Levels
• Cervical Anterior Decompression with Fusion (ADCF) –Single and Multiple Levels 
• Cervical Posterior Decompression with Fusion – Single and Multiple Levels
• Cervical Anterior Decompression (without fusion)
• Cervical Posterior Decompression (without fusion)
• Cervical Artificial Disc Replacement – Single and Multiple Levels  

Evolent (formerly National Imaging Associates, Inc.) does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those listed above.

Please refer the Preauthorization Update for MSK and IPM FAQs and presentation for information 

BCBSNE requires precertification for all acute (non-emergency) inpatient and observation admissions to hospitals or facilities on or before the first day of admission. Unplanned admissions can be submitted the first business day following admission.

To submit a precertification, visit Navinet or if you are an out of state provider, please call 800-247-1103.

Log into NaviNet