Pre-Authorizations for select procedures start August. 1, 2011
July 27, 2011

Beginning Aug. 1, 2011, we're implementing pre-authorization requirements for select medical services to group and individual members. Pre-authorization services are performed to determine if services meet medical necessity criteria, assuring safety, effectiveness and appropriateness of treatment for our members. Our recent analysis has revealed several opportunities to use prior authorization to enhance the quality of care for our members, while better managing overall costs.

Group and individual members will need pre-authorization for the following services with a scheduled date of service of Aug. 1, 2011, or later:

• Hyperbaric oxygen therapy—involves breathing pure oxygen in a pressurized chamber; used to treat decompression sickness, serious infections and wounds and other conditions.
• Intensity modulated radiation therapy (IMRT)—an advanced type of 3D radiation that uses hundreds of small radiation beams of varying intensities to conform to a tumor's shape and precisely radiate it.
• Temporomandibular joint (TMJ) surgical intervention—Temporomandibular joint arthrotomy, temporomandibular joint condylectomy and temporomandibular joint meniscectomy are three examples of this kind of procedure.
• Skilled nursing facility admission—existing requirements have been enhanced. Evaluation of medical necessity for skilled nursing facility care will be done prior to admission. The current practice initiates a review after 10 days, and that practice is being replaced.
• Mental health and chemical dependency residential treatment center—criteria for admission for psychiatric and/or substance abuse conditions have been enhanced. Evaluation of medical necessity for residential treatment center care will be conducted prior to admission instead of the current practice of not reviewing until after the third day of treatment.
• Select durable medical equipment—such as negative pressure wound therapy pumps, oscillatory chest compression devices and ultrasonic osteogenesis stimulators.
  

Certain ASC groups will be exempt from these requirements and will continue to follow their contract customization requirements. Requirements for MedAdvantage members will be implemented in September.

If you have questions, please contact your Regence Sales Team.

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