Blue Cross Blue Shield of Massachusetts (BCBSMA) is initiating a new utilization management program for certain services for our Commercial EPO and PPO Members. These requirements have been in place for our HMO and POS membership and this change aligns our EPO and PPO products with them.

Additionally, they are implementing these medical policies for their Medicare Advantage members.

PPO/EPO/Medicare Advantage Authorization requirement changes:

Effective 1 de janeiro, 2022:

The changes listed below apply to certain services that are covered by their members’ medical benefits.

Prior authorization for commercial EPO, PPO, and Medicare Advantage members:

The following services will have an authorization requirement as of 1 de janeiro, 2022. BCBSMA will begin accepting authorizations 30 days in advance of the requirement date. Members currently using these services or those having one of the services performed will require an authorization for dates of service on or after 1 de janeiro, 2022.

Applies to these services.

Authorization is required for these services for dates of services on or after 1 de janeiro, 2022.

How to request prior authorization

• Providers can contact the BCBSMA authorization area by calling 1-800-676-BLUE

Please note that:

• As always, BCBSMA recommends checking benefits and eligibility to determine the member’s benefits and any authorization requirements.
• All services must continue to meet medical necessity criteria. BCBSMA will only provide reimbursement for services that meet these requirements and for which a prior authorization has been obtained.
• The Medical Policy Router and the General Pre-Requirements will be updated by 1 de janeiro, 2022.

The Medical Policies for BCBSMA’s UM program are now posted. Please refer to these links going forward.