Utilization Review Requirements

Utilization Review Requirements

 

To receive all of the coverage provided by your health plan, you must follow all of the requirements described in this section. Your coverage may be denied if you do not follow these requirements.

Pre-Service Approval Requirements

There are certain health care services or supplies that must be approved for you by Blue Cross and Blue Shield. A health care provider who participates in your health care network should request a pre-service approval on your behalf. (You must request this review if the health care provider does not start the process for you.) For the pre-service review, Blue Cross and Blue Shield will consider your health care provider to be your authorized representative. Blue Cross and Blue Shield will tell you and your health care provider if coverage for a proposed service has been approved or if coverage has been denied. To check on the status of a request or to check for the outcome of a utilization review decision, you can call your health care provider or the Blue Cross and Blue Shield customer service office. The toll free phone number to call is shown on your ID card. Remember, you should check with your health care provider before you receive services or supplies to make sure that your health care provider has received approval from Blue Cross and Blue Shield when a pre-service approval is required. Otherwise, you will have to pay all charges for those health care services and/or supplies.

(The requirements described below in this part do not apply to your covered services when Medicare is the primary coverage.)

Referrals for Specialty Care
You do not need a referral from your primary care provider or your attending physician in order for you to receive your health plan coverage. But, there are certain health care services and supplies that must be approved by Blue Cross and Blue Shield before you receive them. (See below.)

Pre-Service Review for Outpatient Services
To receive all of your coverage for certain outpatient health services and supplies, you must obtain a pre-service approval from Blue Cross and Blue Shield. A health care provider who participates in your health care network will request this approval on your behalf. During the pre-service review, Blue Cross and Blue Shield will determine if your proposed health care services or supplies should be covered as medically necessary for your condition. Blue Cross and Blue Shield will make this decision within two working days of the date that it receives all of the needed information from your health care provider. You must receive a pre-service approval from Blue Cross and Blue Shield for:

  • Certain specialty care, surgical procedures, and/or other outpatient health care services and supplies. These services and supplies may include those that are furnished for you by a covered provider such as a hospital, a professional health care provider (for example, chiropractors and physical and occupational therapists), or a non-emergency ambulance. For your specific plan option, to find out if your proposed service or supply needs a pre-service review, you can check with your health care provider. You can also call the Blue Cross and Blue Shield customer service office or use the online Blue Cross and Blue Shield member self service option. To do this, log on to the Blue Cross and Blue Shield Web site at www.bluecrossma.com. Just follow the steps to check your benefits.
  • Infertility treatment.
  • Home health care. (If you have been receiving inpatient care, Blue Cross and Blue Shield may approve these services through Discharge Planning.)
  • Certain prescription drugs that you buy from a pharmacy or that are administered to you by a non-pharmacy health care provider during a covered visit. For example, you receive an injection or an infusion of a drug in a physician’s office or in a hospital outpatient setting. A key part of this pre-service approval process is the step therapy program. It helps your health care provider provide you with the appropriate drug treatment. To find out if your prescription drug requires a prior approval from Blue Cross and Blue Shield, you can call the Blue Cross and Blue Shield customer service office.

Pre-Approval Requirements Can Change:
 
From time to time, Blue Cross and Blue Shield may change the list of health care services and supplies that require a prior approval. To check these requirements, you can use the online Blue Cross and Blue Shield member self service option. To do this, log on to the Blue Cross and Blue Shield Web site at www.bluecrossma.com. When a material change is made to these requirements, Blue Cross and Blue Shield will let the subscriber’s group on your behalf know about the change at least 60 days before the change becomes effective.

Missing Information
In some cases, Blue Cross and Blue Shield will need more information or records to determine if your proposed health care services or supplies should be covered as medically necessary to treat your condition. For example, Blue Cross and Blue Shield may ask for the results of a face-to-face clinical evaluation or of a second opinion. If Blue Cross and Blue Shield does need more information, Blue Cross and Blue Shield will ask for this missing information or records within 15 calendar days of the date that it received your health care provider’s request for pre-service approval. The information or records that Blue Cross and Blue Shield asks for must be provided to Blue Cross and Blue Shield within 45 calendar days of the request. If this information or these records are not provided to Blue Cross and Blue Shield within these 45 calendar days, your proposed coverage will be denied. If Blue Cross and Blue Shield receives this information or these records within this time frame, Blue Cross and Blue Shield will make a decision within two working days of the date it is received.

Coverage Approval
If through the pre-service review Blue Cross and Blue Shield determines that your proposed health care service, supply, or course of treatment should be covered as medically necessary for your condition, Blue Cross and Blue Shield will call the health care provider. Blue Cross and Blue Shield will make this phone call within 24 hours of the time the decision is made to let the health care provider know of the coverage approval status of the review. Then, within two working days of that phone call, Blue Cross and Blue Shield will send a written (or electronic) notice to you and to the health care provider. This notice will let you know (and confirm) that your coverage was approved.

Coverage Denial
If through the pre-service review Blue Cross and Blue Shield determines that your proposed health care service, supply, or course of treatment should not be covered as medically necessary for your condition, Blue Cross and Blue Shield will call the health care provider. Blue Cross and Blue Shield will make this phone call within 24 hours of the time the decision is made to let the health care provider know that the coverage was denied and to discuss alternative treatment. Then, within one working day of that phone call, Blue Cross and Blue Shield will send a written (or electronic) notice to you and to the health care provider. This notice will explain Blue Cross and Blue Shield’s coverage decision. This notice will include: information related to the details about your coverage denial; the reasons that Blue Cross and Blue Shield has denied the request and the applicable terms of your coverage in this health plan; the specific medical and scientific reasons for which Blue Cross and Blue Shield has denied the request; any alternative treatment or health care services and supplies that would be covered; Blue Cross and Blue Shield clinical guidelines that apply and were used and any review criteria; and the review process and your right to pursue legal action.

Reconsideration of Adverse Determination
Your health care provider may ask that Blue Cross and Blue Shield reconsider its decision when Blue Cross and Blue Shield has determined that your proposed health care service, supply, or course of treatment is not medically necessary for your condition. In this case, Blue Cross and Blue Shield will arrange for the decision to be reviewed by a clinical peer reviewer. This review will be held between your health care provider and the clinical peer reviewer. And, it will be held within one working day of the date that your health care provider asks for Blue Cross and Blue Shield’s decision to be reconsidered. If the initial decision is not reversed, you (or the health care provider on your behalf) may ask for a formal review. The process to ask for a formal review is described in Part 10 of this benefit booklet. You may request a formal review even if your health care provider has not asked that the Blue Cross and Blue Shield decision be reconsidered.

Pre-Admission Review
Before you go into a hospital or other covered health care facility for inpatient care, your health care provider must obtain an approval from Blue Cross and Blue Shield in order for your care to be covered by this health plan. (This does not apply to your admission if it is for emergency medical care or for maternity care.) Blue Cross and Blue Shield will determine if the health care setting is suitable to treat your condition. Blue Cross and Blue Shield will make this decision within two working days of the date that it receives all of the needed information from your health care provider.

Missing Information
In some cases, Blue Cross and Blue Shield will need more information or records to determine if the health care setting is suitable to treat your condition. For example, Blue Cross and Blue Shield may ask for the results of a face-to-face clinical evaluation or of a second opinion. If Blue Cross and Blue Shield does need more information, Blue Cross and Blue Shield will ask for this missing information or records within 15 calendar days of the date that it received your health care provider’s request for approval. The information or records that Blue Cross and Blue Shield asks for must be provided to Blue Cross and Blue Shield within 45 calendar days of the request. If this information or these records are not provided to Blue Cross and Blue Shield within these 45 calendar days, your proposed coverage will be denied. If Blue Cross and Blue Shield receives this information or records within this time frame, Blue Cross and Blue Shield will make a decision within two working days of the date it is received.

Coverage Approval
If Blue Cross and Blue Shield determines that the proposed setting for your health care is suitable, Blue Cross and Blue Shield will call the health care facility. Blue Cross and Blue Shield will make this phone call within 24 hours of the time the decision is made to let the facility know of the coverage approval status of the pre-admission review. Then, within two working days of that phone call, Blue Cross and Blue Shield will send a written (or electronic) notice to you and to the facility. This notice will let you know (and confirm) that your coverage was approved.

Coverage Denial
If Blue Cross and Blue Shield determines that the proposed setting is not medically necessary for your condition, Blue Cross and Blue Shield will call the health care facility. Blue Cross and Blue Shield will make this phone call within 24 hours of the time the decision is made to let the facility know that the coverage was denied and to discuss alternative treatment. Then, within one working day of that phone call, Blue Cross and Blue Shield will send a written (or electronic) notice to you and to the facility. This notice will explain Blue Cross and Blue Shield’s coverage decision. This notice will include: information related to the details about your coverage denial; the reasons that Blue Cross and Blue Shield has denied the request and the applicable terms of your coverage in this health plan; the specific medical and scientific reasons for which Blue Cross and Blue Shield has denied the request; any alternative treatment or health care services and supplies that would be covered; Blue Cross and Blue Shield clinical guidelines that apply and were used and any review criteria; and the review process and your right to pursue legal action.

Reconsideration of Adverse Determination
Your health care provider may ask that Blue Cross and Blue Shield reconsider its decision when Blue Cross and Blue Shield has determined that inpatient coverage is not medically necessary for your condition. In this case, Blue Cross and Blue Shield will arrange for the decision to be reviewed by a clinical peer reviewer. This review will be held between your health care provider and the clinical peer reviewer. And, it will be held within one working day of the date that your health care provider asks for the Blue Cross and Blue Shield decision to be reconsidered. If the initial decision is not reversed, you (or the health care provider on your behalf) may ask for a formal review. The process to ask for a formal review is described in Part 10 of this benefit booklet. You may request a formal review even if your health care provider has not asked that the Blue Cross and Blue Shield decision be reconsidered.

Concurrent Review and Discharge Planning
Concurrent Review means that while you are an inpatient, Blue Cross and Blue Shield will monitor and review the health care services you receive to make sure you still need inpatient coverage in that facility. In some cases, Blue Cross and Blue Shield may determine upon review that you will need to continue inpatient coverage in that health care facility beyond the number of days first thought to be required for your condition. When Blue Cross and Blue Shield makes this decision (within one working day of receiving all necessary information), Blue Cross and Blue Shield will let the health care facility know of the coverage approval status of the review. Blue Cross and Blue Shield will do this within one working day of making this decision. Blue Cross and Blue Shield will also send a written (or electronic) notice to you and to the facility to explain the decision. This notice will be sent within one working day of that first notice. This notice will include: the number of additional days that are being approved for coverage (or the next review date); the new total number of approved days or services; and the date the approved services will begin.

In other cases, based on a medical necessity determination, Blue Cross and Blue Shield may determine that you no longer need inpatient coverage in that health care facility. Or, you may no longer need inpatient coverage at all. Blue Cross and Blue Shield will make this decision within one working day of receiving all necessary information. Blue Cross and Blue Shield will call the health care facility to let them know of this decision. Blue Cross and Blue Shield will discuss plans for continued coverage in a health care setting that better meets your needs. This phone call will be made within 24 hours of the Blue Cross and Blue Shield coverage decision. For example, your condition may no longer require inpatient coverage in a hospital, but it still may require skilled nursing coverage. If this is the case, your physician may decide to transfer you to a skilled nursing facility. Any proposed plans will be discussed with you by your physician. All arrangements for discharge planning will be confirmed in writing with you. Blue Cross and Blue Shield will send this written (or electronic) notice to you and to the facility within one working day of that phone call to the facility. You may choose to stay in the health care facility after you have been told by your health care provider or Blue Cross and Blue Shield that inpatient coverage is no longer medically necessary. But, if you do, this health plan will not provide any more coverage. You must pay all costs for the rest of that inpatient stay. This starts from the date the written notice is sent to you from Blue Cross and Blue Shield.

Reconsideration of Adverse Determination
Your health care provider may ask that Blue Cross and Blue Shield reconsider its decision when Blue Cross and Blue Shield has determined that continued inpatient coverage is not medically necessary for your condition. In this case, Blue Cross and Blue Shield will arrange for the decision to be reviewed by a clinical peer reviewer. This review will be held between your health care provider and the clinical peer reviewer. And, it will be held within one working day of the date that your health care provider asks for the Blue Cross and Blue Shield decision to be reconsidered. If the initial decision is not reversed, you (or the health care provider on your behalf) may ask for a formal review. The process to ask for a formal review is described in Part 10 of this benefit booklet. You may request a formal review even if your health care provider has not asked that the Blue Cross and Blue Shield decision be reconsidered.

Individual Case Management

Individual Case Management is a flexible program for managing your benefits in some situations. Through this program, Blue Cross and Blue Shield works with your health care providers to make sure that you get medically necessary services in the least intensive setting that meets your needs. Under this program, coverage may be approved for services that are in addition to those that are already covered by this health plan. For example, Blue Cross and Blue Shield may approve these services to:

  • Shorten an inpatient stay. This may occur by sending a member home or to a less intensive setting to continue treatment.
  • Direct a member to a less costly setting when an inpatient stay has been proposed.
  • Prevent future inpatient stays. This may occur by providing coverage for outpatient care instead.

Blue Cross and Blue Shield may, in some situations, present a specific alternative treatment plan to you and your attending physician. This treatment plan will be one that is medically necessary for you. Blue Cross and Blue Shield will need the full cooperation of everyone involved. This includes: the patient (or the guardian); the hospital; the attending physician; and the proposed health care provider. Blue Cross and Blue Shield may require that there be a written agreement between the patient (or the patient’s family or guardian) and Blue Cross and Blue Shield. Blue Cross and Blue Shield may also require that there be an agreement between the health care provider and Blue Cross and Blue Shield to furnish the services that are approved through this alternative treatment plan.