Referring physicians must obtain prior authorization from CareCore National for the following services:
- Cardiac Devices
- CT Scans
- Nuclear Cardiology
- PET Scans
- Radiation Therapy
- Sleep Studies
Follow this link to view our list of guidelines which includes current CPT codes that apply to CareCare Services.
Conventional x-rays and ultrasound studies do not require preauthorization. In general, Excellus BCBS follows CareCore National criteria. However, after an independent review of the evidence, our corporate medical policy committee has made limited modifications.
Emergent and Urgent Studies in the Outpatient Setting
The Health Plan will not require preauthorization for imaging studies for an emergency condition when a patient presents in a location other than emergency departments when, in the ordering physician's judgment, the patient’s condition is emergent and directly ordering the study is the most appropriate course of action. Preauthorization is not required when a patient presents in an emergency department.
When emergent imaging studies are done in settings other than the ER, the rendering or ordering provider should call Excellus BlueCross BlueShield within 72 hours after services are rendered to ensure that the Health Plan processes the claims appropriately. Please call the dedicated number at 1-800-536-2484, or send a fax to 1-800-292-5109.
What is considered an "emergency condition?"
Although most clinical emergencies present in the emergency room setting, occasionally emergent clinical conditions do present in the outpatient (facility or office) setting. Many physicians have asked Excellus BlueCross BlueShield to create a specific list of diagnoses that would clearly divide emergent from non-emergent clinical situations. However, many medical conditions have diverse clinical presentations (e.g., rule out appendicitis, which can have both sub-acute and acute clinical presentations). Therefore, Excellus BlueCross BlueShield does not believe a diagnosis code set is practical. As stated previously, when in the ordering physician's clinical judgment, the patient’s condition is emergent and ordering the study directly is the most appropriate course of action, pre authorization will not be required by Excellus BlueCross BlueShield. The ordering physician should contact the radiologist directly and the radiologist should render the test.
Will these studies be reviewed?
Although these services will not require preauthorization, the Health Plan will track and trend use of the "emergency" outpatient imaging process. If trends are identified that demonstrate higher utilization of emergency notifications, the Health Plan will work with the ordering and/or rendering physicians to educate and clarify the process.
In order to identify why the utilization rate is higher for an individual provider compared to a peer group, the Health Plan will review imaging studies for emergency conditions for clinical appropriateness on a retrospective basis.
Urgent Imaging Studies
The Health Plan will require pre authorization for urgent imaging studies performed in the outpatient setting.
How can physicians request urgent review?
It is strongly recommended that physicians call CareCore National to initiate urgent requests. If the fax method must be used, physicians must clearly mark "URGENT" in capital letters on the fax cover sheet.
What is the turnaround time for urgent review?
During CCN regular business hours (Monday through Friday from 7 a.m. to 7 p.m.), the timeframe for decisions on urgent cases is three hours from the receipt of all necessary demographic and clinical information. For this reason, it is best to call CCN to initiate urgent requests. If a patient requires urgent imaging after business hours, the physician may order the test and then contact CareCore National within two business days to obtain authorization. When contacting CCN, be sure to indicate that the imaging was performed urgently and give the date of service to ensure that the authorization will be dated correctly.
Responsibilities of the Ordering Provider
Ordering providers are required to complete the online preauthorization information via the Web, fill out the preauthorization request fax forms or call CCN for pre authorization. It is important to state that you are requesting preauthorization for an Excellus BlueCross BlueShield member.
Please have the following information on hand to expedite the process:
- The patient's name, date of birth, phone number and insurance plan member ID number
- The ordering provider's name, provider ID number, fax and phone number
- The rendering provider’s information, including facility name, fax and phone number
- The CPT code and/or description of the test requiring pre authorization
- Patient data relevant to the request: signs and symptoms, test results, medications, related therapies, dates of prior imaging studies, etc.
When a procedure is approved, the ordering provider will contact the patient to schedule the procedure.
Appeals can be initiated by a member or the provider if there is ongoing disagreement with the decision. Appeals for preauthorization can also be expedited. Both pre- and post-service appeals must be submitted to the Health Plan. To appeal a denied authorization or claim, contact the Health Plan.
Medicare appeals for preauthorization denials are to be submitted through the Health Plan. Members may begin the appeal process by contacting the dedicated Medicare Unit at 1-866-846-8643. Providers may contact the Health Plan’s Provider Service department to initiate an appeal.
Commercial appeals for preauthorization denials are to be submitted directly to the Health Plan. Providers may contact the Health Plan’s Provider Service department to initiate an appeal. Claims appeals are conducted after a claim has been denied on the provider remittance you receive from the Health Plan. To appeal a denied claim, contact the Health Plan.