Utilization Management (UM) Decision and Notification Timeliness

The UM department is committed to performing decision and notification activities in a consistent and timely manner to minimize disruption in the provision of health care for its members. Blue Cross and Blue Shield of Nebraska (BCBSNE) makes timely UM decisions and provides notification to the member, practitioner and provider according to the clinical urgency of the service request. UM decisions are made in compliance with state, federal and accrediting agency regulations. Leaders perform ongoing monitoring of adherence to established time frames. Opportunities for improvement are conducted at the individual staff level and department-wide.  

Clinical Review Required Specifics  
BCBSNE must review and approve select services before they are provided. The primary reason for clinical review is to determine whether the service is medically necessary, whether it is performed in the appropriate setting and whether it is a benefit.  

Criteria and Guidelines for Decisions  
InterQual criteria adopted by the plan are updated annually and include CMS Medicare Guidelines and also the following: 

Clinical Review Determination  
Clinical information is necessary for all services that require clinical review to determine medical necessity. In addition to reviewing clinical information, BCBSNE Care Management evaluates:  

• The member’s eligibility coverage and benefits 
• The medical need for the service  
• The appropriateness of the service and setting  

If additional clinical information is required to approve the service, a BCBSNE Care Management representative telephones the provider to ensure that all needed information is received in a timely manner, a written request may also be sent to the member or provider receiving the authorization.  

Submit the Required Clinical Information with the Initial Review Request  
Providers are encouraged to submit the required clinical information with the initial request for clinical review sent via Fax.

Clinical Information for Part B Medication Prior Authorization can be submitted by faxing it to 855-342-9648.  

Clinical information for Acute and Post Acute Hospital Admissions can be submitted by faxing it to Care Management at 866-422-5120.  

BCBSNE is required by Medicare to notify members as to what clinical information is needed to process a request for clinical review when not provided at the time of request. When providers submit the clinical information with the initial request, it decreases the number of letters BCBSNE is required to send to members.  

Standard Time Frames for All Requests for Service  
BCBSNE conducts timely reviews of all requests for service, according to the type of service requested. Decisions are made: 

Notification of Decisions:

Medications Covered Under the Medical Benefit (Part B Medications)  
Certain medications covered under the medical benefit (Part B medications) require clinical review (Prior Authorization). These medications are not self-administered and are typically administered in a specialty clinic or physician office. These drugs are managed by BCBSNE through the Pharmacy department.  

Drugs that are subject to clinical review and the clinical information required for a decision are listed on BCBSNE Provider Procedures.  

For these drugs, providers may submit the clinical review request in one of the following ways:

• By calling 877-399-1671 or the After Hours 877-399-1674 
• By faxing a completed Medical Benefit Drug Request Form along with supporting documentation to the fax number, 855-342-9648. This form can be accessed via NebraskaBlue.com/Providers/BCBSNE-Provider-Procedures/Medicare-Advantage-Policies. 

Note: For medications covered under the pharmacy benefit (Part D medications), providers must contact the Medicare Advantage Clinical Pharmacy Help desk at: 855-457-1351.  

NOC Codes Related to Part B Medication Require Clinical Information  
Certain medications with “not otherwise classified” codes do not require a prior authorization and will be reviewed as a post-service request. 

• The NOC codes included are J3490 and J3590 

Note: NOC codes are also referred to as “unclassified codes,” “unlisted codes” and “unspecified codes.”  

Clinical Review for Part B Medications  
The pharmacist reviews the clinical information, using established criteria and the member’s benefits. Clinical information includes relevant information regarding the member’s: 

• Health history 
• Physical assessment 
• Test results 
• Consultations 
• Previous treatment 

Note: Reference the Medical Benefit Drug Request form via the BCBSNE Website: BCBSNE Provider Procedures  

Clinical information should be provided at least 14 days prior to the service. The provider is responsible for ensuring authorization. BCBSNE provides a reference number on all authorizations.  

If clinical information is not received with the request, BCBSNE contacts the physician or facility verbally to request the necessary documentation. In addition, follow-up letters are sent to the member and the provider requesting the required information. If documentation is not submitted within the designated time frame, the service is denied. 


* InterQual® and Clear Coverage™ are trademarks or registered trademarks of McKesson Corporation and/or one of its subsidiaries, an independent company providing services for Blue Cross and Blue Shield of Nebraska.