Blue Cross Blue Shield of Massachusetts: Radiology and Sleep Apnea Program Expansion

Blue Cross Blue Shield of Massachusetts is expanding our high-technology radiology and sleep apnea program to our Medicare Advantage PPO and HMO members. Please see the announcements below for each of the programs.

High-tech Radiology/Imaging
Effective January 1, 2018, BCBSMA is expanding our high-technology radiology and sleep apnea program managed by AIM Specialty Health to our Medicare Advantage HMO and PPO members.

Prior authorization requirements will apply to all Medicare Advantage PPO and HMO members.

Beginning January 1, 2018, our radiology prior authorization requirements will apply to all Medicare PPO and HMO members. These requirements will apply 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 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 December 1, 2017, providers can submit requests and check for a member’s authorization for dates of service of January 1, 2018 or later.

Obstructive Sleep Apnea Program
We will expand our existing program for obstructive sleep apnea (OSA) services for our Medicare Advantage HMO and PPO members on January 1, 2018. Our existing program has successfully helped maintain affordability for our members while ensuring that our members receive clinically appropriate services.

Beginning January 1, 2018, we will include Medicare Advantage PPO and HMO members in our prior authorization program for the following services:

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

Starting December 1, 2017, ordering providers can submit requests and check for a PPO member’s authorization for dates of service of January 1, 2018 or later.

Questions
If you have questions, please speak with a BCBSMA provider service representative by calling the BlueCard Eligibility line 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.