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Preauthorization

The services below require prior review by the Plan to determine clinical medical necessity.

Not all services are covered by all medical plans. There may be services which require preauthorization or notification that do not require clinical review. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service. For questions about preauthorization, call 1-800-363-4658.

Service Commercial & Medicare Products Safety Net Products
  including but not limited to: HMO, EPO and Healthy Blue PPO, Exchange Products (through Envolve-New York, Inc.)
Abdominoplasty and Panniculectomy Required Required
Ablative techniques for treating Barrett’s Esophagus and treating primary and metastatic liver malignancies Not Required Required
Acoustic Cardiography Required Not Required
Adenoidectomy Not Required Required
Air Ambulance (Non-Emergent) Required Required
Anesthesia for Dental Surgery Required Required
Aqueous Drainage Devices Required Not Required
Balloon Sinuplasty Required Required
Bariatric Procedures Required Required
BRCA Testing Required Required
Blepharoplasty Required Required
Breast Reconstruction, including but not limited to Implant Insertion, Removal, Reinsertion (except for breast cancer diagnosis) Required Required
Breast Reduction Surgery, including surgery for Gynecomastia Required Required
Cardiac Devices, Implantable
View Cardiac Implantables CPT Codes (PDF)
Required through eviCore Healthcare Required through eviCore Healthcare
Cardiovascular Telemetry Devices, Wearable, Mobile Required Not Required
Chelation Therapy Required Required
Cholecystectomy, Laparoscopic Required Not Required
Clinical Trials * Required Commercial only
* For Medicare Advantage members, Medicare approved clinical trials are covered by original Medicare or FFS Medicare and should be billed directly to your fiscal intermediary. Crossover claims will be sent directly to the plan by the intermediary. Be sure to use the correct clinical trial codes.
Required
Cochlear Implants and Auditory Brain Stem Implants Required Required
Collagenase; Clostridium Histolyticum Xiaflex Required Required
Comfort; Convenience, Cosmetic or Custodial Services or Procedures Required Not Required
Compression Garments Not Required Required
Computer Assisted Navigation for Knee and Hip Arthroscopy Required Required
Contact Lenses Not Required Required
Contact Lenses, Gas Permeable Scleral Required Required
Continuous Glucose Monitoring Devices Required Not Required
Cosmetic Services (refer to published procedure code list) Required Required
Cranial Orthotics Required Required
Cryosurgical Tumor Ablation Required Required
Deep Brain Stimulation Required Required
Dermabrasion Required Required
Durable Medical Equipment
DME Procedure Codes Requiring Preauthorization (PDF)
Required for all equipment listed below or when member contract requirements dictate:
  • Airway Clearance Devices
  • Ambulatory Traction Devices
  • BiPAP
  • Bone Growth Stimulators
  • Continuous Glucose Monitoring Systems
  • Functional Neuromuscular Stimulators
  • Gait Trainers
  • Hospital Beds (including Air Fluidized Beds)
  • Insulin Pumps
  • Intrapulmonary Percussive Devices
  • Pneumatic Cervical Traction Devices
  • Pneumatic Compressors (Lymphedema Pumps)
  • Speech Generating Devices
  • Stander / Standing Devices
  • T.E.N.S. units
  • Wheel Chairs and Power Operated Vehicles
  • Wound Vac

Required for all equipment listed below or when member contract requirements dictate:

  • Airway Clearance Devices
  • Ambulatory Traction Devices
  • BiPAP
  • Bone Growth Stimulators
  • Continuous Glucose Monitoring Systems
  • Functional Neuromuscular Stimulators
  • Gait Trainers
  • Hospital Beds (including Air Fluidized Beds)
  • Insulin Pumps and External Insulin Delivery systems
  • Intrapulmonary Percussive Devices
  • Oxygen Equipment
  • Pneumatic Cervical Traction Devices
  • Pneumatic Compressors (Lymphedema Pumps)
  • Speech Generating Devices
  • Stander / Standing Devices
  • T.E.N.S. units
  • Wheel Chairs and Power Operated Vehicles
  • Wound Vac
  • Other Select DME items – refer to published Preauthorization Code List
Enteral and Parenteral Therapy Not Required Required
Experimental and Investigational Procedures and / or Services Required Required
Gastric Neurostimulation Required Required
Genetic Testing Required Required
Hearing Aids Not Required Required
Home Care & Home Infusion Nursing Visits Required Required
Home Tele-Monitoring (this is not Cardiac Surveillance) Not Covered Required (excludes Child Health Plus and Family Health Plus)
Home Uterine Monitoring Required Not Required
Hospice Services Not Required Required
Hospital to Hospital Transfers Required Required
Hyperbaric Oxygen Therapy Required Required
Hyperhidrosis Surgery Required Required
Hysterectomy (excludes primary female reproductive cancer diagnosis) Required Required
Inpatient Admissions (except routine maternity) to any facility including hospital, elective and direct admit, acute rehab, SNF, mental health, chemical dependency and hospital to hospital transfers.
* Emergency admissions require notification to the Health Plan.
Required Required
Inpatient Admission to the Neonatal Intensive Care Unit (NICU) Required Required
Joint Surgery Procedures including Replacement: Ankle, Elbow, Hip, Interphalangeal, Knee, Metacarpophalangeal, Shoulder, Wrist Required for:
Hip
Knee
Shoulder
Required for:
Ankle
Elbow
Hip
Interphalangeal
Knee
Metacarpophalangeal
Shoulder
Wrist
Keloid Scar Revision Required Required
Knee Replacement; includes Unicondylar Required Required
Left Ventricular Assist Devices (LVAD) Required Required
Lung Volume Reduction Surgery Not Required Required
Magnetic Esophageal Ring for treatment of GERD Required Required
Maze Procedure for treatment of Atrial Fibrillation Not Required Required
Medical Specialty Drugs
Reference Medical Specialty Drug Guidelines for frequently updated list.
Required Required
Miscellaneous & Unlisted Codes Required Required
Muscle Flap Procedures Not Required Required
Neuromuscular Stimulation for Scoliosis and electrical shock units Required Required
Neuropsychological Testing Required Required
Non-Participating Providers Required (PPO products excluded) Required
Orthopedic / Orthotic Devices Required for custom knee braces and cranial orthotics only or unless member contract limitations apply. Required for Select Orthopedic Devices - Refer to DME Procedure Codes Requiring Preauthorization (PDF)
Osteochondral Bone Graft Required Required
Otoplasty Required Required
Pain Management Services Not Required Required
Palatopharyngoplasty
Uvulopalatopharyngoplasty
Required Required
Personal Care Services Not Covered Required (Safety Net Only)
Platelet Rich Plasma for wound healing, each unit Required Required
Prolotherapy Required Required
Prosthetic Devices Required for:
Computerized prosthetic legs; "C" legs
Miscellaneous and Unlisted "L" codes, or unless member contract limitations apply
Required for:
Computerized prosthetic legs; "C" legs
Additional select codes - Refer to published Preauthorization Code list
Radiology (Imaging) Services
(excludes imaging performed in the inpatient, observation and emergency room settings)
Refer to Radiology CPT code list (PDF)
  • CTs & CTAs
  • MRAs
  • MRIs
  • Nuclear cardiology
  • All PET scans (Positron Emission Tomography)
Miscellaneous or unlisted radiology procedure codes
  • CTs & CTAs
  • MRAs
  • MRIs
  • Nuclear cardiology
  • All PET scans (Positron Emission Tomography)
Miscellaneous or unlisted radiology procedure codes
Radiation Therapy
Including but not limited to IMRT, SRS and Proton Beam Therapies
Refer to Radiation Oncology CPT Codes (PDF)
Required through eviCore Healthcare Required through eviCore Healthcare
Refractive Procedures Required Required
Rhinoplasty / Septoplasty Required Required
Sacral Nerve Stimulation for Pelvic Floor Dysfunction Required Required
Septoplasty Required Required
Sexual Reassignment Surgery Required Required
Skin Substitutes Required Not Required
Sleep disorders; surgical management of Required Required
Sleep Disorder Management includes Sleep Studies, PAP Devices & Supplies
Refer to View Sleep Disorder/Sleep Studies CPT Codes (PDF)
Required through eviCore Healthcare Required through eviCore Healthcare
Spine Surgery Program Required for all procedures listed below regardless of place of service:
  • Allograft for Spine Surgery
  • Arthrodesis / Fusion
  • Arthroplasty; Artificial Disc
  • Autograft for Spine Surgery
  • Decompression Procedure(s); Spine
  • Discectomy including Osteophytectomy
  • Intraspinous Distraction (X-Stop)
  • Kyphoplasty
  • Laminectomy
  • Laminotomy / Laminectomy; percutaneous
  • Minimally Invasive Technique for Lumbar Fusion
  • Vertebral Corpectomy
  • Vertebroplasty; Percutaneous
Required for all procedures listed below regardless of place of service:
  • Allograft for Spine Surgery
  • Arthrodesis / Fusion
  • Arthroplasty; Artificial Disc
  • Autograft for Spine Surgery
  • Decompression Procedure(s); Spine
  • Discectomy including Osteophytectomy
  • Intraspinous Distraction (X-Stop)
  • Kyphoplasty
  • Laminectomy
  • Laminotomy / Laminectomy; percutaneous
  • Minimally Invasive Technique for Lumbar Fusion
  • Vertebral Corpectomy
  • Vertebroplasty; Percutaneous
  • For additional Spine Surgery codes please see Spinal Surgery section in the published code list (PDF).
Spinal Cord Stimulation Required Required
Stereotactic Radiosurgery (SRS) Required Required
Therapy; Occupational Required
Preauthorization is not required for Medicare Advantage Direct Pay members. These are subject to the Therapy Cap Benefit.
Required
Therapy; Physical Required
Preauthorization is not required for Medicare Advantage Direct Pay members. These are subject to the Therapy Cap Benefit.
Required
Therapy; Speech Required
Preauthorization is not required for Medicare Advantage Direct Pay members. These are subject to the Therapy Cap Benefit.
Required
Tonsillectomy Not Required Required
Transplants Required Required
Transportation Not Required Required
Vagus Nerve Stimulation Required Required
Varicose Vein Treatment Procedures
(including, but not limited to: Vein Ligation, Sclerosing Injection, VNUS and Laser procedures)
Required Required
Vision Services Eyewear Not Required Required
Vision Therapy Required Required
Wound Filler Not Required Required
Yttruim-90, Selective Internal Radiation Therapy (SIRT) Required Required

Note: You'll need your Facets Provider ID to use Clear Coverage or do Pre-Service Reviews at Other Blue Plans. Get Your Facets Provider ID   View new Clear Coverage Features (PDF)

Step 1: Check the Patient's Benefits & Coverage for plan-specific preauthorization requirements.

Step 2: Submit Your Request

For these Services: Request Authorization:
A. Requests for Safety Net (through Envolve-New York, Inc.)
(See section B below for Commercial and Medicare Requests.)
 Please Note: eviCore applies to Safety Net policies too.

CLEAR COVERAGE

Inpatient:  
Medical -
Elective & Prospective Admissions

Outpatient:  
Medical -
All Procedures on Prior Authorization List
Behavioral Health - All Procedures on Prior Authorization List

 Please Read: Attestation Information
Provider: Online with Clear Coverage
Clear Coverage Elective Procedures and Outpatient Services Manual (PDF)

You can also FAX or call in your requests. See the appropriate service below for contact information

Behavioral Health Envolve will handle behavioral health preauthorizations and case management.
For case management inquiries, call: 1-844-694-6411
For behavioral health preauthorization, FAX or call in your requests to: FAX: 1-844-878-6989 Phone: 1-844-694-6411
Envolve FAX Form for Inpatient Preauthorization Requests (PDF)
Envolve FAX Form for Outpatient Preauthorization Requests (PDF)
Please use this form for Medicaid Managed Care and HARP (Blue Option Plus & Premier Option Plus) lines of business only
NeuroPsychological Testing Authorization Request Form (PDF)
Outpatient Treatment Authorization Request Form (PDF)
Adult Behavioral Health Home and Community Based Services (BH HCBS): Prior and/or Continuing Authorization Request Form (PDF)
Medical Intake Envolve will handle preauthorizations request.
FAX or call in your requests to: FAX: 1-844-279-7140 Phone: 1-844-694-6411
Concurrent review information can be faxed to: 1-855-742-0126
Inpatient form should be used for Observation Level of Service.
Envolve FAX Form for Inpatient Preauthorization Requests (PDF)
Envolve FAX Form for Outpatient Preauthorization Requests (PDF)
Medical Specialty Drug
(for Medicaid and Child Health Plus)
Envolve will handle medical specialty drug preauthorizations for Managed Medicaid and Safety Net only and they will use the Excellus BCBS Medical Specialty Drug list (PDF).
Fax or call in your requests to: FAX: 1-855-346-4418 Phone: 1-844-694-6411
Envolve FAX Form for Inpatient Preauthorization Requests (PDF)
Envolve FAX Form for Outpatient Preauthorization Requests (PDF)
B. Requests for Commercial and Medicare
Implantable Cardiac Devices, Radiology/Imaging, Radiation Therapy or Sleep Studies/Supplies Online with eviCore healthcare, or call 1-866-889-8056
 Please Note: eviCore applies to Safety Net policies too.
Urgent/Emergent Medical Admissions (Facility)  Please Read: Attestation Information
Facility: Online with Clear Coverage, call 1-800-363-4658, or FAX to 1-800-292-5109
Clear Coverage Acute Medical-Surgical Inpatient Manual (PDF)
Clear Coverage Acute Medical-Surgical Inpatient Tip Sheets (PDF)
Inpatient Elective/Prospective Admissions (Provider)
Outpatient Procedures on Prior Authorization List
(Home Care, Physical, Occupational & Speech Therapy must use Clear Coverage.)
 Please Read: Attestation Information
Provider: Online with Clear Coverage, call 1-800-363-4658, or FAX to 1-800-222-8182
Clear Coverage Elective Procedures and Outpatient Services Manual (PDF)
Clear Coverage Elective Procedures and Outpatient Services Tip Sheets (PDF)
Other Emergency Admissions Request to Customer Care: call 1-800-363-4658
Other Elective Admissions Request to Customer Care: call 1-800-363-4658
Other Surgical/Medical Authorizations Request to Customer Care: call 1-800-363-4658
Medical Specialty Drug
(for Commercial, Exchange and Medicare)
 Please Read: Attestation Information
Provider: Online with Clear Coverage

Or you can contact the Excellus BCBS Medical Specialty Drug Unit, call 1-800-306-0151, or FAX to 1-800-306-0188.
Refer to our Medical Specialty Drug list (PDF) and our Drug Prior Authorization FAX Forms page.
Urgent Requests After-Hours (weekdays after 5 p.m. and weekends EST) Call 1-877-303-8887 (nurses will collect information to be entered into our systems the next business day)
Members of Other Blue Plans (Pre-Service Review) Online, or call the number on the Member's ID Card

Accessing eviCore healthcare Online

If you experience difficulty connecting from our website to eviCore healthcare, please call our Web Security Help Desk at 1-800-278-1247. For questions about using the eviCore healthcare website, please call eviCore healthcare directly at 1-800-918-8924 ext 10036.

  • DME Providers: At this time we cannot accept online authorization requests for Durable Medical Equipment via eviCore. Please call eviCore directly at 1-866-889-8056.
  • Referring Providers: Site Selection is not required for all prior authorized services. If it is required you will be asked to provide this information during the auth creation process on the eviCore Web Portal.

Radiology Urgent / Emergent Requests

Emergent Studies
We do 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 us within 72 hours after services are rendered to ensure that we process 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 us 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, we do 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, we will not require preauthorization. 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, we will track and trend use of the "emergency" outpatient imaging process. If trends are identified that demonstrate higher utilization of emergency notifications, we 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, we will review imaging studies for emergency conditions for clinical appropriateness on a retrospective basis.

Urgent Imaging Studies
We 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 eviCore healthcare 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 eviCore healthcare 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 eviCore healthcare to initiate urgent requests. If a patient requires urgent imaging after business hours, the physician may order the test and then contact eviCore healthcare within two business days to obtain authorization. When contacting eviCore National, 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 eviCore healthcare 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

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, please contact us.

Medicare appeals for preauthorization denials are to be submitted through us. Members may begin the appeal process by contacting the dedicated Medicare Unit at 1- 866-846-8643. Providers may contact our Provider Service department to initiate an appeal.

Commercial appeals for preauthorization denials are to be submitted directly to us. Providers may contact our 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, please contact us.