Thursday, November 8, 2018

CPT code Prolotherapy therapy (proliferative therapy) - 20999


Prolotherapy therapy (proliferative therapy) is a method to try to heal joints and connective  tissue. A solution is injected in the area. The solution irritates the tissue, causing inflammation.  This inflammation is supposed to stimulate the body’s natural healing response. These injections  are repeated over time. The hope is to gradually build up new issue in the injured area and  restore strength. Prolotherapy is investigational (unproven). The studies that have been done are  small and don’t show substantial improvement. There’s not enough medical evidence to show if  this technique works.

Note: The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy  informs them about when a  service may be covered 

Coding Code Description

CPT 20999 Unlisted procedure,  musculoskeletal system, general

HCPCS  Description

Prolotherapy  describes a procedure  intended for healing and strengthening ligaments and  tendons by injecting an agent that induces inflammation and stimulates endogenous repair  mechanisms.  Prolotherapy may also be referred to as proliferant injection, prolo, joint  sclerotherapy, regenerative injection therapy, growth factor stimulation injection, or nonsurgical  tendon, ligament, and joint reconstruction M0076 Prolotherapy


The goal of prolotherapy is to promote tissue repair or growth by prompting release of growth  factors, such as cytokines, or by increasing the effectiveness of existing circulating growth  factors due to injection of an irritant solution. The mechanism of action is not well - understood  but may involve local irritation and/or cell lysis. Agents used with prolotherapy have included  zinc sulfate, psyllium seed oil, combinations of dextrose , glycerin , and phenol, or dextrose alone, often combined with a local anesthetic. Polidocanol and  sodium morrhuate, vascular sclerosants,  have also been used to sclerose areas of high intratendinous blood flow associated with  tendinopathies.  Prolotherapy typically involves multiple injections per session conducted over a  series of treatment sessions.

A similar treatment approach involves the injection of autologous platelet - rich plasma, which  contains a high concentration of platelet - derived growth factors.Treatment of musculoskeletal  pain conditions (eg, tendinopathies) with PRP is discussed in a sepa rate policy (see  Related  Policies ).

Summary of Evidence

For  individuals who have musculoskeletal pain (eg, chronic neck, back pain),  osteoarthritic pain,  or  tendinopathies of the upper or lower limbs includes ,the evidence includessmall randomized trials with inconsistent results. Relevant outcomes are symptoms, functional outcomes, and quality of life. The strongest evidence evaluates the use of prolotherapy for the treatment of  osteoarthritis, but the clinical significance of  the  therapeutic  results is  uncertain. The evidence is  insufficient to determine the effects of the technology on health outcomes

Practice Guidelines and Position Statements

American Association of Orthopaedic Medicine

The American Association of Orthopedic Medicine currently has a recommendation posted  online for the use of prolotherapy for back pain. The Association has indicated that “...prolotherapy should be considered a valid treatment option in a selected group of chronic low back pain patients.”Medicare National Coverage The Coverage Issues Manual #35 - 13 states that prolotherapy, joint sclerother apy, and  ligamentous injections with sclerosing agents are not covered, noting that the medical effectiveness of these therapies has not been verified by scientifically controlled studies. In 1999,  on request for reconsideration of coverage of prolotherapy for treatment for chronic low back pain, Medicare retained its noncoverage decision for prolotherapy, citing a lack of scientific  eviden ce on which to base a decision.

Regulatory Status

Sclerosing agents have been approved by the U.S. Food and Drug Administration for use in  treating spider and varicose veins. These sclerosing agents include Asclera® (polidocanol),  Varithena® (an injectable polidocanol foam), Sotradecol® (sodium tetradecyl sulfate), Ethamolin® (ethanolamine oleate), and Scleromate® (sodium morrhuate). These agents are not  currently approved as joint and ligamentous sclerosing agents

Wednesday, October 24, 2018

CPT CODE 0398T, 0071T, 0072T - Magnetic resonance procedure


Magnetic resonance - guided  high - intensity ultrasound uses two technologies: magnetic  resonance imaging (MRI) and ultrasound. It is a noninvasive procedure, which means  the skin is  not cut .  MRI uses a magnetic field, radio frequency, and a computer to create detailed images of  organs, tissues, and bones. Ultrasound uses sound waves  at a higher frequency  than a person  can hear.  Ultrasound is usually used to create images of  body  structures to help diagnose  illnesses.  But in this treatment, the ultrasound beams are at a different frequency and are  focused on one area.  Heat is created at the point where the high frequency beams meet , and  the heat ablates ( destroys )  unhealthy tissue . The MRI is used to both guide the location of the  ultrasound beams and  to  monitor treatment. This policy discusses when magnetic resonance - guided high - intensity ultrasound ablation may be considered medically necessary and covered  by the health plan.

The Introduction section is for your general knowledge and is not to be  taken as policy coverage criteria . The  rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for  providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider  also can be a place where medical care is given, like a hospital, clinic, or lab. This policy  informs them about when a  service may be covered.

Documentation Requirements

The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should  include the following:
* Documentation that the requested service is for pain control  that has failed  for patient  with bone  metastases, or not a candidate for radiotherapy
* Documentation that patient has essential tremors not responding to medication (such as beta - blockers or anticonvulsants)

Coding Code Description CPT

0398T Magnetic resonance image guided high intensity focused ultrasound (MRgFUS),  stereotactic ablation lesion, intracranial for movement disorder including stereotactic  navigation  and frame placement when performed
0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume of less than 200 cc of tissue
0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance;  total  leiomyomata volume greater or equal to 200 cc of tissue
53899 Unlisted procedure, urinary system
55899 Unlisted procedure, male genital system
76999 Unlisted ultrasound procedure (eg diagnostic, interventional

Note :  CPT codes, descriptions and  materials are copyrighted by the American Medical Association (AMA). HCPCS  codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Magnetic resonance - guided high - intensity ultrasound ablation of uterine fibroids is  specifically  identified by the following category III CPT codes:
* 0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total  leiomyomata volume of less than 200 cc of tissue
* 0072T As above, but with total leiomyomata volume great er or equal to 200 cc of tissue.

These CPT codes should not be used with 51702 (insertion of temporary indwelling bladder  catheter, simple) or 77022 (magnetic resonance imaging guidance for, and monitoring of,  visceral tissue ablation). Before the introduc tion of the specific category III CPT codes, the  procedure may have been coded using several codes describing the individual components of  the procedure. CPT codes 0071T - 0072T describe the comprehensive service.

The procedure may be performed in a magnetic resonance imaging suite with an open magnetic  resonance scanner, which might not be available at many institutions. The procedure is  performed in an outpatient setting, with the patient under conscious sedation. There are no specific CPT codes for the use of magnetic resonance - guided high - intensity  ultrasound ablation in metastatic bone cancer. An unlisted code would be used based on the  anatomic location of the metastasis being treated (eg, 23929 for the clavicle) or perhaps an  unlisted radiation oncology code (eg, 77299 or 77499)

Consideration of Age
Magnetic resonance*guided focused ultrasound (MRgFUS) is considered medically necessary for  bone metastases in adult patients, age 18 and older.
This is based on the randomized controlled  trial that studied the use of MRgFUS in  patients with  bone metatsase

Evidence Review Description
An integrated system providing magnetic resonance*guided focused ultrasound (MRgFUS) treatment is proposed as a noninvasive therapy for uterine fibroids and pain palliation of bone  metastases. MRgFUS is also being investigated as a treatment of other benign and malignant  tumors.

Uterine Fibroids

Uterine fibroids are one of the most common conditions affecting women in the reproductive  years. Symptoms of uterine fibroids include menorrhagia, pelvic pressure, or pain.

Several approaches currently available to treat symptomatic uterine fibroids include: hysterectomy, abdominal myomectomy, laparoscopic and  hysteroscopic myomectomy,  hormone therapy, uterine artery embolization, and watchful waiting. Hysterectomy and various  myomectomy procedures are considered the  criterion standard treatment.

Metastatic Bone Disease
Metastatic bone disease is one of the most common causes of cancer pain.  Treatment Existing treatments include conservative measures ( eg, massage,  exercise) and pharmacologic  agents ( eg, analgesics, bisphosphonates, corticosteroids). For patients who  do not respond to  these treatments, standard care is external - beam radiotherapy. However, a substantial  proportion of patients have residual pain after radiotherapy, and there is a need for alternative
treatments for these patients.   One option, radiofrequency a blation, is addressed in a  related policy.

Essential Tremors
Essential tremor (ET) is the most common movement disorder, with an estimated prevalence of 5% worldwide. ET most often affects the hands and arms, may affect the head and voice, and rarely includes the face, legs, and trunk. ET is heterogeneous among patients, varying in frequency, amplitude, causes of exacerbation, and association with other neurologic deficits

The neuropathology of ET is uncertain, with some evidence suggesting that ET is localized in the  brainstem and cerebellum. If patients with ET experience intermittent or persistent disability due  to the tremors, initial therapy is with  drugs (*-blockersor anticonvulsants). For medicine-refractory patients, surgery (deep brain stimulation or thalamotomy) may be offered, though high rates of adverse events have been observed

Magnetic Resonance*Guided Focused Ultrasound
Magnetic resonance - guided focused ultrasound  ( MRgFUS ) is a noninvasive treatment that  combines  2  technologies : focused ultrasound and magnetic resonance imaging (MRI). The  ultrasound  beam penetrates through the soft tissues and, using MRI for guidance and monitoring, the beam can be focused on targeted sites. Ultrasound causes a local increase in temperature in the target tissue, resulting in coagulation necrosis while sparing the surrounding normal structures. Ultrasound waves from each sonication are  directed  at a focal point that has a  maximum focal volume of 20 nm in diameter and 15 nm in height/length. This causes a rapid  rise in temperature (ie , to 65°C - 85°C), which is sufficient to  ablate  tissue at the focal point. In  addition to providing guidance, the associated MRI can provide online thermometric imaging, a  temperature “map” , to confirm the ther apeutic effect of the ablation treatment and allow for real - time adjustment of the treatment parameters

The U.S. Food and Drug Administration (FDA) has approved the ExAblate MRgFUS system (InSightec) for two indications : treatment of uterine fibroids (leiomyomata) and palliation of pain associated with tumors metastatic to bone. The ultrasound equipment is specially designed to be compatible with magnetic resonance magnets and is integrated into standard clinical MRI  units; it also includes a patient table, which  has  a cradle  that houses  the focused  ultrasound transducer in  water or  a  light oil bath. Some models have a detachable cradle; only certain  cradle types can be used for palliation of pain associated with metastatic bone  cancer. For  treating pain associated with bone metastases, the aim of MRgFUS is to destroy nerves in the  bone surface surrounding the tumor. MRgFUS is also being investigated for treatment of other tumors, including breast, prostate,  brain , and desmoid tumors as well as nonspinal osteoid osteoma.(For prostate cancer see Related Policy8.01.61 Focal Treatments for Prostate Cancer)

Summary of Evidence

For individuals who have uterine fibroids who receive MRgFUS, the evidence includes  2  small RCT s , nonrandomized comparative studies, and case series. Relevant outcomes are symptoms,  quality of life, resource utilization, and treatment - related morbidity.  One RCT (N=20)  has  reported some health outcomes, but its primary purpose was to determine the feasibility of a  larger trial. It did not find statistically significant differences in quality of life outcomes between  active and sham treatment groups, but it did find lower fibroid volumes after active treatment.  This trial  did not have an  active comparator , the clinical significance of the primary outcome was  unclear, and there were no follow - up data beyond 1 year.  The second RCT (N=49) is ongoing;  preliminary results at 6 weeks posttreatment, comparing MRgFUS with uterine artery  embolization  have shown that the 2 groups  are comparable in medication use and symptom  improvement following treatments. Patients in the MRgFUS group reported recovering  significantly faster than patients in the
uterine artery embolization  group, as measured by  time  to return to work and time to normal activities. In  a separate  2013 comparative study, outcomes  appeared to be better with uterine artery embolization than with MRgFUS.  Long - term data on  the treatment effects, recurrence rates, and impact on future fertility and pregnancy are lacking .  The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals  with  metastatic bone cancer who failed or are not candidates for radiotherapy who receive MRgFUS, the evidence includes a sham- controlled randomized trial and several case  series . Relevant outcomes are symptoms, functional outcomes, health status measures, quality  of life, and treatment - related morbidity. The RCT found statistically significant improvements after MRg FUS in a composite outcome comprised of reduction in pain and morphine use, and in  pain reduction as a stand - alone outcome. A substantial proportion of patients in the treatment  group experienced adverse events, but most  events were  transient and not severe.  The case  series reported reductions in pain following MRgFUS treatment, consistent with the RCT.  The  evidence is sufficient to determine that the technology results in a meaningful improvement in  the net health outcome

Friday, August 24, 2018

Basics of Dental Billing and vision care billing in APG payments


Dental services provided in the clinic setting (hospital or free-standing) are to be billed using the APG payment methodology. The only exception to this policy is orthodonture, which is to be billed to the dental practitioner fee schedule and not to APGs. Orthodontic procedures are identified as those D codes grouping to APG 371 – Orthodontics. Again, APG 371 is a non-payable APG. Providers will continue to be required to obtain prior approval for orthodontic procedures. E&M codes should not be billed for any dental services. All dental services should be billed using only D codes Effective January 1, 2010, medical visits will no longer package with dental procedures or exams. When a patient has a medical visit (i.e., with a practitioner other than a dentist) and a dental visit on the same day, both the medical visit and the dental exam will pay at the line level.

Effective February 1, 2010, dental professional services are included in the APG payment to the facility and may not be billed by dentists using the Medicaid dental fee schedule. Specifically, no D codes (other than those used for orthodonture) are billable against the practitioner fee schedule. Dentists and/or oral surgeons should not bill Medicaid fee-for-service for non orthodontic D codes but may submit a claim for their professional services to the facility (i.e., the APG biller). If a practitioner is enrolled in Medicaid as both a dentist and a physician he/she may submit a separate [non-APG] professional claim for services payable off the physician schedule. If a procedure requires three encounters to complete, a clinic should claim for the applicable procedure code for each distinct date of service. However, APGs 373 Level I Dental Film, 374 Level II Dental Film, and 375 Dental Anesthesia will not pay if there are no other procedures claimed for the applicable date of service. For dates of service beginning January 1, 2009, when multiple dental procedures are performed on the same date of service, the highest weighted procedure will pay at 100% and all other dental procedures will be discounted (at 50%). This will be the case even for procedures that group to the same APG. Multiple same APG consolidation has been eliminated for dental services.

The procedure code for dental sealants (D1351), should be coded once for each tooth that is sealed on a single date of service. If four teeth are sealed during a visit, the code D1351 should appear on each of four claim lines, each with the same date of service. Beginning on January 1, 2011, dental sealants will become a units-based procedure, to be coded on only a single claim line – with the number of teeth sealed shown in the units field. The following are the dental ancillary procedure APGs: 373 Dental Film, 374 Level II Dental Film, 375 Dental Anesthesia, 376 Diagnostic Dental Procedures, and 377 Preventive Dental Procedures. All dental ancillaries pay at the line level. Multiple ancillaries that group to the same APG will be discounted by 50%, whereas multiple ancillaries that group to different APGs will be paid at 100%.

For APG dental billing the 837i claim format must be used, not the 837d claim form.

Dental code D9920 -- behavior management (for patients with mental retardation or a developmental disability) groups to APG 999 and will not pay under the APG reimbursement methodology.

Reimbursable services provided to recipients with recipient exception codes 81 or 95 will receive a 20% higher operating payment. This rate enhancement will begin July 1, 2010 for hospital clinics (using rate code 1501 for visit billing or 1489 for episode billing). Immediately upon the D&TCs transition to the APGs, and retroactive to September 1, 2009, free-standing clinics will receive the 20% rate enhancement for MR/DD/TBI patients under rate code 1435 (the MR/DD/TBI episode rate code 1425 is pended due to the lack of CMS approval of the Dec. 2009 D&TC State Plan Amendment).

Effective April 1, 2010, oral sedation in dentistry (D9248- Sedation (non-iv)) will be paid based on a procedure based weight. This code is to be used only for MR/DD/TBI recipients (as defined by recipient exception codes 81 or 95). Since there are currently no edits in place relative to this code, it is possible to improperly bill for this code. As with any violations of Medicaid billing policy, improper claims are subject to take back accompanied by possible legal action. Please check for the recipient eligibility prior to billing D9248.


Most vision care services are covered in the APG payment methodology. However two vision care services; “the fitting of spectacles: monofocal, bifocal, or multifocal” , “the fitting of spectacles and the eyeglass materials” are carved out of APGs and are billed using rate codes 1226 and 1227 respectively.

4.4 ANCILLARY LABORATORY SERVICES AND RADIOLOGY PROCEDURES: Under the new APG payment methodology, payment for laboratory and radiology services ordered by practitioners in hospital-based outpatient clinics is made to the clinic. When the hospital or D&TC patient receives the ancillary service from someone other than the clinic, the clinic is responsible for paying the individual or entity providing the ancillary service, even in the absence of a contractual relationship between the two parties. The ancillary service provider may not bill Medicaid directly for lab or the technical component of radiology services related to an APG-reimbursed visit and therefore must bill the ordering clinic for the service provided to clinic patients. This ancillary billing policy will be implemented prospectively in DTCs, effective January 1, 2011.

For example, when a practitioner in Clinic A orders a lab test or radiology service that it is not able to provide and the patient goes to Provider B (separate hospital, lab or a radiology group) to receive the service, Clinic A will be responsible for billing eMedNY for the ancillary service and making arrangements to pay Provider B for the delivery of the service. Clinic providers may wish to develop or revisit existing contractual arrangements with laboratory and radiology providers to ensure the availability of ancillary services for their patients and to avoid payment issues upon the implementation of the new APG payment methodology. This payment policy also applies to hospital ED units in the event that the ED physician orders an ancillary laboratory or radiology service that is provided to the patient subsequent to the ED visit.

Hospitals are and effective January 1, 2011 D&TCs will be responsible for advising outside lab and radiology service providers on the order for the service when the payment for the ancillary service is subject to APG reimbursement and the APG ancillary billing policy. They must also advise radiology service providers if they want the provider to “read” the radiology results and bill Medicaid directly for these professional services. Alternatively, if the hospital provider plans to bill for “reading” the radiology result, the hospital should advise the radiology vendor not to bill for the professional component of the radiology service. Only one professional component per radiology procedure per recipient may be billed to Medicaid.

Friday, June 15, 2018

How to do the correction in Medical record after claim submission

Corrections in the Medical Record

If the original entry in the medical record is incomplete, contracting providers shall follow the guidelines below for making a correction, addendum, or amendment. Signature requirements as defined above apply to all corrections in the medical record.

a. Errors in paper-based records:

To add an addendum or amendment to paper-based records, draw a single line in ink through the incorrect entry, print the word "error" at the top of the entry, the reason for the change, the correct information, and authenticate the error by signing (including credentials) the notation with the date and time. Entries should not be antedated (assigned a date earlier than the current date). Errors must never be blocked out or erased.

b. Electronic medical records/Electronic health records:

i. Addendum

An addendum is new documentation used to add information to an original entry that has already been signed. Addenda should be timely with date and time of the addendum. Write “addendum” and state the reason for the addendum referring back to the original entry.

Complete the addendum as soon after the original note as possible. Identify any sources of information used to support the addendum. Entries should not be antedated (assigned a date earlier than the current date).

ii. Amendment

An amendment is documentation meant to clarify or provide additional information within the medical record in conjunction with a previous entry. An amendment is made after the original documentation has been completed and signed by the provider. All amendments should be timely with the date and time of the amended documentation. Write “amendment” and document the clarifying information referring back to the original entry.

Complete the amendment as soon after the original note as possible. Entries should not be antedated (assigned a date earlier than the current date).

5. Use of Medical Scribes

Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider. BCBSKS expects the signing and dating of all entries made by a scribe to be identifiable and distinguishable from that of a physician or licensed independent practitioner. All entries made by a scribe are ultimately the practitioner’s responsibility; therefore, review of the documentation and verification of its accuracy, including authentication by the practitioner, is required.

BCBSKS requests for medical records

1. BCBSKS staff members conduct medical review of claims and seek the advice of qualified and, typically, practicing professionals when necessary. Contracting providers agree to accept the decisions made as a result of those reviews and to follow the appeals procedures established by this Policy Memo.

2. The entire review process itself includes the development of guidelines that relate to specific provisions of members' contracts; the processing of claims based on guidelines and medical records when indicated; the retrospective review of claim determinations; and the appeal process. BCBSKS seeks the advice of clinical professionals at appropriate points throughout the entire review process.

3. Contracting providers must submit all pertinent and complete medical records to BCBSKS within the time frame specified by BCBSKS when records are needed for the initial review of a claim or when records are requested for an audit. In most instances, BCBSKS will allow 30 calendar days for the production of the requested records. In certain unusual circumstances as determined solely by BCBSKS, BCBSKS will require providers to submit medical records without advance notice. In such cases, a BCBSKS representative will visit the provider's office during business hours and secure the requested records immediately. The provider agrees to provide the requested records immediately. Members' contracts permit BCBSKS to obtain medical records without a signed patient release.

4. The ordering/referring provider shall also provide medical records to the performing provider when requested for the purpose of medical necessity review. Additional documentation that is not a part of the medical record and that was not provided at the time of the initial request will not be accepted. Only records created contemporaneous with treatment will be considered pertinent. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.

5. If BCBSKS determines that the patient services provided by the contracting provider are not medically necessary, the claim is denied and is a write-off to the provider. If the services are requested by the patient after being advised by the provider of the lack of medical necessity and the daily record or patient chart has been documented to that effect and a written waiver is obtained by the provider before the service being rendered, charges for the services will be the patient's responsibility.

Friday, May 18, 2018

Basics of Utilization review and medical necessity


The contracting provider agreement requires providers to cooperate in utilization review and medical necessity determinations. Utilization review is the process of determining the appropriateness of services rendered to and payments made on behalf of members. Appropriateness of service and payment determinations consist of the following activities:


Medical necessity policy applies to all services rendered to BCBSKS members and includes any services or supplies used to diagnose and/or treat illness or injury. The service should be widely accepted by a peer group of practicing providers, based on scientific criteria and determined to be reasonably safe. Health care professionals should discuss all appropriate treatment alternatives available to patients regardless of benefit coverage limitations. To be determined medically necessary, the service must be consistent with the diagnosis and treatment of the condition; be in accordance with standards of good health care practice; and not be for the convenience of the patient or provider. The following procedures/equipment would be subject to medical necessity and utilization review:

1. Established procedures/equipment of questionable current usefulness in the treatment of a specific condition(s).

2. Procedures/equipment which tend to be redundant when performed/supplied in combination with other procedures/equipment; or procedures/equipment which are unlikely to provide additional medical benefits, or are contradicting to one another.

3. Specific procedures/equipment or patterns of care which vary significantly from a peer group.


Before admitting a member to a hospital for elective (non-obstetrical, non-life threatening) inpatient care, medical information will need to be supplied to BCBSKS in order to certify medical necessity. A length of stay will be assigned at the time of pre-certification and will be subject to concurrent review. Concurrent review is the process of obtaining current medical information to review for the medical necessity of a requested extension to the length of stay or course of treatment. For the most accurate and complete information, all pre-admission certification should be validated through the BCBSKS provider portal (Availity®).

BCBSKS pre-admission certification and concurrent review activity are conducted in compliance with URAC guidelines. This includes the availability of either the expedited or standard appeal to services denied for medical necessity during the pre-admission certification and concurrent review processes. To initiate an appeal (phone or fax), you must have complete information since the time frame begins with the appeal request. These appeal options are only available prior to claim submission and are subject to time frames as established by BCBSKS, Department of Labor, and URAC. All pre-admission certification appeals for professional and hospital services will be reviewed concomitantly.


Under certain circumstances, pre-certification/prior authorization may be required for outpatient services/procedures. BCBSKS will notify contracting providers at least 30 days in advance of such requirement.

Pre-certification/prior authorization may also be required for other outpatient services such as home medical equipment and case management, including those services specified by employers, and outpatient procedures which necessitate a greater level of facility care than is usually needed.

Following provider notification, continued failure to complete pre-certification/prior authorization activities will result in a 50 percent Maximum Allowable Payment (MAP) reduction up to $200 with the member held harmless. Compliance audits will take place on a post-payment basis, which may result in refunds


Case management is a process that identifies and coordinates alternative treatment plans to enhance care through effective administration of available health care resources in the most cost-efficient manner. The process is accomplished through the development of a treatment plan by the patient or legal representative, the physician, other health care providers, and the BCBSKS case manager.


BCBSKS will identify any trends or patterns of patient care, i.e., through data analysis, which appear inconsistent with overall patterns or trends. Prepayment review will be implemented if attempts to work with the provider have failed to resolve the issue. Specific utilization guidelines may be applied to individual prepay members. Prepayment review means all claims will be reviewed before payment and records will be required.


The provider agrees to use (to the extent possible) those inpatient, extended care, ancillary services and other health facilities and health professionals which have contracted with BCBSKS. Providers agree to render services to members in the most appropriate and economical setting consistent with the member’s diagnosis, treatment needs, and medical condition. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally requesting contract cancellation. In the event members request referrals to non-contracting providers, providers should have patients sign a statement acknowledging full understanding of the non-contracting referral and the patient’s financial responsibilities. The statement should be filed in the patient’s chart.


Providers agree to work with BCBSKS and other providers of care in the resolution of any utilization or medical review problems that may be identified. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally contract cancellation.


Occasionally BCBSKS does not consider an item or service to be medically necessary. In such situations the item or service becomes a provider write-off. In the few situations where services are known to be denied as not medically necessary (including deluxe items) and the patient insists on the services, the provider must obtain a patient waiver in advance of the services being rendered. (See Section X. WAIVER FORM)

Failure to discuss the above with the patient in advance, document this in the medical record, and obtain the waiver will result in a provider write-off.

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