Blue Cross Blue Shield of Massachusetts: BCBSMA High Tech Radiology and Sleep UM Programs

BCBSMA is expanding their high-technology radiology and sleep apnea program for their commercial PPO members. Please see the announcements below for each of the programs.

High-tech Radiology/Imaging
Effective June 1, 2017, BCBSMA will be making changes to our high-technology radiology Utilization Management program managed by AIM Specialty Health.

Currently, BCBSMA requires precertification or prior authorization for high-technology radiology services rendered to members of our commercial HMO/POS plans and Medicare HMO plans. In order to ensure that the quality and affordability of care is protected for all of our members, we are expanding our existing program for high-technology radiology to include commercial PPO members both in-state and out of state.

Beginning June 1, 2017, prior authorization requirements will expand and apply to all commercial PPO members for all of the following services:

• CT & CTA
• Screening & diagnostic CT colonography
• MRI/MRA/MRS/fMRI
• Nuclear cardiac studies
• PET
• CT PET Fusion

Please note that:

• All tests must continue to meet BCBSMA medical policies. We will only provide reimbursement for tests that meet these requirements and for which a prior authorization has been obtained.
• Providers only need to request prior authorization for services rendered on an elective, outpatient basis. Prior authorization is not required when the member receives services via the emergency department, as an inpatient or observation, or when performed as part of outpatient surgery.

Starting May 1, 2017, providers can submit requests and check for a PPO member’s authorization for dates of service of June 1, 2017 or later by:

• Going to AIM Specialty Health’s ProviderPortal (available 24/7). Click on Web Applications User Login located on the right-hand side of the page.
• If you are new user, click on Register Now to complete the online registration form. Once logged in, you may input information to start the case.
• If you currently use AIM Specialty Health’s website for high-technology radiology or sleep studies authorizations, you do not need to re-register.
• Calling AIM Specialty Health at 1-866-745-1783 (Monday-Friday, 8 a.m.-5 p.m.).

Obstructive Sleep Apnea Program
To protect the quality and affordability of care for all of our members, BCBSMA is expanding our existing program for obstructive sleep apnea (OSA) services administered by AIM Specialty Health to our commercial PPO members both in-state and out of state. Currently, our obstructive sleep apnea program is limited to our commercial HMO/POS members.

Effective June 1, 2017, to ensure that obstructive sleep apnea testing takes place in the most appropriate site, we will require prior authorization for the following services for our commercial PPO members:

• Home sleep test (HST)
• In-lab sleep study (PSG)
• Initial and ongoing treatment orders for durable medical equipment and supplies related to sleep therapy: APAP, CPAP, BPAP
• Titration study
• Oral appliances for sleep therapy

Starting May 1, 2017, providers can submit requests and check for a PPO member’s authorization for dates of service of June 1, 2017 or later by:

• Going to AIM Specialty Health’s ProviderPortal (available 24/7). Click on Web Applications User Login located on the right-hand side of the page.
• If you are new user, click on Register Now to complete the online registration form. Once logged in, you may input information to start the case.
• If you currently use AIM Specialty Health’s website for high-technology radiology or sleep studies authorizations, you do not need to re-register.
• Calling AIM Specialty Health at 1-866-745-1783 (Monday-Friday, 8 a.m.-5 p.m.).

Questions
If you have questions, please speak with a BCBSMA provider service representative by calling BlueCard Eligibility at 1-800-676-BLUE (2583). If the BCBSMA member’s ID card does not include an alpha prefix, please call the provider service phone number on the ID card.