Changes to Musculoskeletal (MSK) Program Prior Authorization for Commercial Plans: new Codes are added to the MSK Prior Authorization List: effective date 05/01/2021
This change only applies to to Blue Network P SM and Blue Network S SM unless stated otherwise.
The codes will require an authorization for the members that have the MSK Program Benefit.
The following codes will be added:
Full Name of this policy is: Multiple Procedure Reduction on the Technical Component of Diagnostic Cardiovascular and Ophthalmology Procedures Payment Policy
Effective Date is February 03/2021
This policy will follow the reimbursement standards set forth by the CMS, under the MVP Multiple Procedure Payment Reduction (MPPR) policy. The MPPR policy regarding diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPR policy applies independently to cardiovascular and ophthalmology services. The MPPR policy applies to TC-only services, and to the TC of global services.
For cardiovascular services: 100% reimbursement is made for the TC service with the highest payment. Reimbursement is made at 75% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day.
For ophthalmology services: 100% reimbursement is made for the TC service with the highest payment. Reimbursement is made at 80% for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same group NPI) to the same patient on the same day. The MPPR policy does not apply to the professional component.
The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures are in Attachments 1 and 2 of CR7848 respectively. CR7848 is available at http://www.cms.gov/Regulations[1]and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf
Source: MVP provider fax announcements.
As of January 1, 2021 the following MVP Plans will no longer require prior authorization for High Tech Radiology Services:
MVP Medicare Advantage Plans
MVP Medicaid Managed Care
MVP Harmonious Health Plan (HARP)
MVP Child Health Plus (CHP)
These services include: MRI/MRA, PET Scan, Nuclear Cardiology, CT/CTA, and 3D Rendering Imaging Services
This applies only to the services rendered by IN Network Providers. For any of the above mentioned plans that do have Out of Network benefits and would like to go to an out of network provider: the Prior Authorization is Required!
To request an authorization: please complete a Prior Approval Request Form (PARF) and fax it to MVP at 1-800-280- 7346.
ALL other MVP plans still require a prior authorization for HIGH Radiology Services. To request an Auth please contact eviCore Healthcare by submitting requests at evicore.com or by calling 1-800-568-0458.
#MRI, #MRA, #PET, #MVPCHP, #MVPHARP
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