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New Authorization Rules for MediBlue HMO (VOF prefix)
Please make sure your staff is aware that Empire MediBlue Plus HMO and Empire MediBlue Core HMO members
assigned to a Healthcare Partners (HCP) IPA primary care provider now require authorizations and pre-certifications through HCP MSO.
What to do?
PCPs -- If you are in network with HCP IPA then you must obtain all pre-certifications through HCP MSO. You may use EZ-Net or fax HCP authorization forms to 888-746-6433. The specialists will not be able to do this on their own! Furthermore, CSI must bill HCP IPA instead of Blue Shield.
Specialists -- You must be aware if the patient's PCP is par or non-par with HCP IPA. Of course the question is how can you tell? The answer can be obtained by checking eligibility. Under the coverage section you will find a message such as "independent physician association name: Healthcare Partners MSO". For HCP MSO patients you need to obtain a printout of the electronic pre-authorizations. For regular Blue Shield (non-HCP) patients you do not need paper referrals for visits but do need Evicore pre-authorizations for procedures.
Empire MediBlue Services that Require Pre-Authorization
Click
here for a complete list of services that require authorization for ANY Blue Shield MediBlue plan (VOF-, VOG-, JWX- prefix). Here are some highlights for our specialist clients:
- Cardiac Catheterization
- PCI Stent
- Vascular Ultrasound
- Pacemaker Insertions
- Nuclear Cardiac
- Echocardiograms
- Endoscopies
- Tonsillectomy / Adenoidectomy
- Sleep Studies
- UPPP
- Physical Therapy
- Pain Management
Insurances are continuing to utilize third party solutions for authorizations, claim reviews, and chart auditing. We will continue to update you as we learn about new changes. Ultimately, I believe these systems are designed not only to reduce the insurance's cost but also to inject confusion and complexity into the claims process. We need to continue to learn and change so we can maximize your income.
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