Medical Pharmacy Solutions Requirements

Starting December 2, 2024, providers can contact the Medical Pharmacy Solutions team at Prime to obtain prior authorizations (also known as precertifications or prior approvals) for the in-scope clinician administered drugs for our members with dates of service on or after Monday, December 9, 2024.

The program will apply to all Fully Insured and Self-Funded Commercial members and all Individual and Small Group Health Insurance Marketplace BCBSND members. CHAND members are also included.

OUT OF SCOPE: FEP, Medicaid Expansion, Medicare, Medicare Supplement, Medicare Advantage, Medigap, Women's Way and Colorectal Cancer Plan

Providers directly contracted with BCBSND may request access to the Prime provider portal.

To do so, visit Prime’s provider portal at www.gatewaypa.com and complete the following steps:

• Click on New Provider Access Request under the sign in box.
• Complete the form and click “Register.”

Please have the following information ready:·

• Requestor’s name, email address, and phone number
• Health plan name
• Provider, facility, or group name
• Provider, facility, or group service address
• Tax ID number
• NPI
• Practice Administrator name and email address (if not the requestor)

*Please allow up to two business days for a response by email.

If a provider is not directly contracted with BCBSND, Prime will advise them via email that they must call in their PA request to Prime’s intake team (800)424-1708. They will be able to check the status of their authorizations on Prime’s portal using the tracking number (provided by Prime’s intake team at the time of the request) by selecting Track an Authorization on GatewayPA.com.

They can email Prime at providerinquiry@primetherapeutics.com.

Providers directly contracted with BCBSND may request non-urgent authorizations on the Prime secure provider portal at www.gatewaypa.com. For urgent authorization requests, Providers should call Prime at (800) 424-1708. This phone number is BCBSND specific. Hours of operation are 8 a.m. to 6 p.m. CT for non-urgent requests, and 24 hours per day/7 days per week for urgent requests. All urgent requests must be communicated to Prime via phone request.

To expedite prior authorizations, the provider should have the following information:

• BCBSND member name, date of birth and ID number
• Member height and weight
• Ordering provider name, tax ID number, NPI, practice address, and office telephone and fax numbers
• Rendering provider name, tax ID number, NPI, practice address, and office telephone and fax numbers (if different from ordering provider)
• Requested medical drug name or HCPCS code
• Anticipated start date of treatment
• Dosing information and frequency
• Diagnosis (ICD-10 code)
• Any additional clinical information pertinent to the request

If requested by Prime, the provider should be prepared to upload the following documents to the Prime provider portal, or to fax the following documents to Prime’sHIPAA-compliant fax:·
 

• Clinical notes
• Pathology reports
• Relevant lab test results

Please note: It is the responsibility of the ordering provider to obtain prior authorization before services are provided. If the ordering provider and the rendering providerare different, the rendering provider is responsible for ensuring that the appropriate approval is on file prior to rendering services.

Authorizations issued by BCBSND for dates of service before Dec. 9, 2024, for the medical drugs included in this program will be effective until the authorization end date originally provided by BCBSND. To continue treatment after the original authorization end date, a new authorization approval from Prime must be obtained prior to the expiration date. Claims for dates of services after the authorized end date will be denied if a provider has not obtained a successive authorization from Prime.

Yes. In most cases, approvals can be made based on the initial information provided to Prime by the requestor. If there is a question or concern regarding the information provided, the case will be sent to a clinical pharmacist who will reach out to the requesting provider. The case will be escalated to a Prime physician if the pharmacist cannot reach an agreement regarding the appropriate use of the requested medical drug. A Prime physician will discuss the case with the provider. In accordance with plan guidelines, an appropriate course of action and case determination will be communicated via letter back to the provider and member.

Yes. Prior authorization requests cases are processed under a clinically expedited schedule if the standard processing times would:

• Place the patient’s life at risk.
• Cause the potential of loss of limb.
• Put the member at risk of being hospitalized.

Medical drug approvals for members are valid for all network Providers who share the Tax Identification Number (TIN) on the authorization.

Providers who already have an established account on GatewayPA may email providerinquiry@primetherapeutics.com to request that BCBSND be added to their account.

You can send a message to Prime through the provider portal if the provider is directly contracted with BCBSND. If it is an urgent request, you can call Prime at (800) 424-1708.

No. Prime provider portal users who are linked to the practice TIN will be able to conduct transactions for every network clinician linked to the practice TIN. Each user will have to have their own account and an administer can be assigned.

It is pended to be clinically reviewed by a Prime clinical pharmacist.

The initial clinical reviewer can approve the prior authorization request.

The clinical pharmacist reviewer will schedule a peer-to-peer conversation between the provider and Prime peer clinical reviewer, who is a board-certified physician. The Prime peer clinical reviewer will render the final determination based on the information received.

Note: Prime initial clinical reviewers are clinical pharmacists.

BCBSND will manage appeals for medical drugs.