Preauthorization and Precertification

Preauthorization

Preauthorization is based on the terms of the covered person’s contract and information submitted to Blue Cross and Blue Shield of Nebraska (BCBSNE). Preauthorization guidelines, found in the BCBSNE Medical Policy, apply when BCBSNE is the primary payer; no preauthorization is required when BCBSNE is secondary to any other insurance (including Medicare or another Blue Plan). When BCBSNE is secondary, our medical policy will still apply.  

Payment for services requiring preauthorization must have preauthorization approval in the BCBSNE system. A provider’s submission of a preauthorization request acts as a provider attestation that all information included is accurate. If no approval is obtained before the service is rendered, the claim will be denied as “no preauthorization obtained.” Medical necessity review upon appeal will not be done except for FEP or if the service was rendered under emergent circumstances.   

Using the BCBSNE Medical Policy tool, providers have real-time access to the most current information and can search for a medical policy by keyword, policy number or procedure code.  

Providers may submit online preauthorization's directly from NebraskaBlue.com/Providers. Providers will then be asked to log in to NaviNet to complete submission.  

The provider will enter the procedure code(s), select the appropriate Medical Policy and review the guidelines per the member’s clinical presentation. If all criteria are met, the provider may receive automatic approval. If the criteria are not met, the request will be pended for medical review. Include all contact information and medical records with the pended preauthorization.  

Preauthorization requests are processed in the order they are received. If the procedure will not be scheduled until the preauthorization has been completed, enter the date the doctor would like to perform the service as the scheduled procedure date.  

Preauthorization's that are not urgent will be processed within 15 calendar days of receipt unless additional medical records are needed to review the request. If information is requested, providers are given no less than 30 calendar days to submit additional information. The patient is given no less than 45 calendar days to submit additional information.

A preauthorization determination will be made upon receipt of the information or the end of the extension period.

If a rush request is received, the request will not be placed in a rush status unless it meets the status for an urgent preauthorization. The requestor will be notified that the anticipated decision date will be 15 days from the date of submission.

In the case of an urgent preauthorization, the claimant/provider will be notified of the decision within 72 hours of receipt, unless further information is needed. If additional information is necessary, the claimant/provider will be given at least 48 hours from the date of the request to provide the specified information. We will communicate our decision within 48 hours of receiving the additional requested information, or the end of the period allowed to provide the information.   

An authorization is effective for six months, unless otherwise specified. All authorizations are based on the terms of the member benefit plan as of the authorization date. Benefits are based on the member’s plan as of the date services are received.  

Changes in the patient’s coverage for any reason, including eligibility, benefit revisions, or contractual maximums, may affect the approval.  

Any time there is a question of whether a procedure or service is covered by BCBSNE, the provider should try to determine if a preauthorization is needed by checking MedPolicy Blue.  

Note: All medical policy criteria and preauthorization requirements applicable to out-of-state Blue Cross and/or Blue Shield patients are dictated by the Blue Plan that insures the member. Refer to “Medical Policy and Pre-cert Lists for all Blue Plans” for preauthorization requirements for the member’s plan.  

Radiology Preauthorization Program

BCBSNE has implemented a Radiology Quality program to promote the most appropriate use of advanced imaging services. The program aligns with the goals of the Nebraska Health Care Reform Task Force: To promote high quality, affordable health care coverage and utilize the best practices and practice guidelines to help reduce unnecessary medical expenses.  

The ordering provider/office should complete the preauthorization. Radiology providers/free-standing imaging centers should confirm from the ordering provider that a preauthorization has been obtained. Authorizations are valid for 60 days from the date of submission of the authorization.  

To submit a preauthorization for a radiology service, you will need a NaviNet account. Once logged into NaviNet, click on the preauthorization tool link on the left side of the screen. 

How the program works

• If the member’s clinical information provided meets InterQual criteria, the user will be issued an auto authorization.
• If all criteria are not met and additional information or review is needed, authorization will be pended. Attach clinical documentation or include in the online Note section along with your office’s contact information. If a member’s clinical information is not included, this will be requested for review by our nurses or medical staff.

NIA Magellan Spine Pain Management Program  

BCBSNE’s spine pain management program is part of our commitment to member safety and promoting continuous quality improvement for services. We work with National Imaging Associates, Inc. (NIA), a Magellan Health Services company, for administration of this program.   

This program includes prior authorization for two components of non-emergent spine care: (1) outpatient interventional pain management (IPM) services and (2) inpatient and outpatient cervical and lumbar spine surgeries:

BCBSNE oversees the program and is responsible for claims adjudication and medical policies. NIA manages non-emergent outpatient IPM services and inpatient and outpatient cervical and lumbar spine surgeries through the specialist contractual relationship with BCBSNE.  

Valuable information to note:

• It is the responsibility of the ordering physician to obtain preauthorization for all interventional spine pain management procedures and spine surgeries outlined above.  
• NIA does not manage prior authorization for emergency spine surgery cases that are admitted through the emergency room or for spine surgery procedures outside of those procedures listed above.  
• Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in non-payment of the claim.  
• Facilities must continue to follow BCBSNE’s prior-authorization requirements for hospital admissions and elective surgery based on the member’s benefit and coverage requirements.  
• Any BCBSNE prior authorization requirements for the facility or hospital admission must be obtained separately and should only be initiated after the surgery has met NIA’s medical necessity criteria.  
• NIA Magellan’s clinical guidelines can be found at RadMD.com.

Precertification

BCBSNE requires precertification for all acute inpatient (medical and surgical) and inpatient observation admissions for BCBSNE members and their dependents on Day One of coverage.  

Planned admissions may be certified on or before admission date.

• Precertification notification for unplanned admissions should occur on the first business day following admission.

This requirement does not apply to: 

• Members with Medicare Supplement coverage  
• Members for whom BCBSNE is secondary to another payer  
• Hospital stays for labor and delivery (48- or 96-hour admissions)  
• Preauthorization is required if the patient is transferred to a lower level of care, such as skilled nursing or home health facility, on the first day. All other hospitals and residential treatment centers must call us on the first inpatient day.  

Federal Employee Program (FEP) Members  
Precertification requirements apply to FEP members. If precertification is not obtained when required for FEP members, a $500 precertification penalty will be applied to the provider’s reimbursement if care is determined to be medically necessary.  

***Please note: ALL inpatient admissions for gastric-restrictive procedures require precertification to confirm the member has met requirements for medical necessity. If precertification is not done and care is determined to be medically necessary, the $500 penalty will be applied. If the precertification is not done and the care is determined NOT medically necessary, all charges will be denied.  

Adhering to these requirements will prevent the above precertification penalties from being passed to providers and/or members. Outpatient surgery does not require precertification. If the patient subsequently needs to be admitted as an inpatient, then precertification is required on the first day.