Blue Cross Blue Shield of North Dakota (BCBSND) wants to continue to provide transparency and guidance as BCBSND and providers navigate the new Predictal precertification tool that went live Saturday, Nov. 11, 2023.
As a reminder, provider’s need to exit after each submission by clicking the blue “Exit AAH” button in the top right-hand corner, as noted in Step 20. This ensures a prior member’s details won’t populate on a new precertification request.
Precertification Requests for molecular and genomic testing
Our Utilization Management (UM) team is seeing an increase in precertification requests for molecular and genomic testing. Precertification for genetic testing should be submitted directly to eviCore, not through Availity Essentials. Any requests submitted within Availity Essentials, will be cancelled without review.
Information on precertification and claims policy are on eviCore's website https://www.evicore.com/resources/healthplan/blue-cross-blue-shield/north-dakota, under the Solution Resources tab.
Availity Essentials Authorization Dashboard
Your dashboard will display requests that were submitted through the Availity Essentials Portal. If the request is faxed or needs to be manually entered into the system by our Utilization Management (UM) team, due to it needing to be fixed, the request will not display on the Availity Essentials dashboard. While it can be searched for manually and pinned to your dashboard, the timeliest option would be to enter all authorization requests directly in the Availity Essentials portal.
We understand some providers submit many authorization requests, however, there is no current functionality to display a message prompt on the dashboard when something additional is needed or a request is updated. When additional documentation is needed for a review, it will prompt a request to you via the Pending status. If the request was submitted within Availity Essentials, you will need to view the request in the portal. If submitted via fax, a fax requesting the information will be sent to the fax number submitted on the request. If you have an issue reading the fax received, utilize the Availity Essentials portal prior to contacting the Provider Service department. Providers also have the option to filter results to narrow searches by specific criteria, which can help you find submitted requests.
Remember, you can also see the determination rationale within the dashboard by clicking on the specific case. For requests that show a cancelled status, you may see the dashboard showing a “withdrawn” reason, to get further cancellation reason information, you can go into the Predictal. For those requests not submitted electronically, expect a letter containing rationale details in the mail for denied requests.
There are still concurrent review requests that are within our old system for requests that came in prior to the go live of Predictal, these will not show on the Availity dashboard, as stated in our prior HealthCare News (HCN) article.
The How to use your Dashboard and Authorization/Referral Dashboard Status Actions sections in the Predictal process guide can also be used for reference.
Eligibility Details Impacting Submission Requests
There are a few circumstances in which a provider may need additional assistance submitting a request when a member’s eligibility dates have changed, they have switched group numbers, or have primary/secondary insurance.
Providers should submit precertification requests under the primary UMI for the member. The system is unable to determine a member’s primary insurance when going through the submission workflow. If a provider needs help determining what plan is primary for the member, they can utilize the Eligibility & Benefits search within Availity Essentials or call Provider Services at the phone number on the back of the member ID card.
There are also times a member's eligibility date changes due to a retroactive change or the member has changed employer groups for example, which could potentially display a new effective date. If a provider is trying to submit a request for coverage prior to the effective date of the plan, it will not work, even if the person has the same UMI. If a provider needs to submit a request for a member with a date prior to their effective date displaying, the request should be faxed in for review.
Importance of Selecting the Correct Service Type
When submitting an authorization, you will need to select a service type. This service type assists in routing your case to a Blue Cross Blue Shield of North Dakota (BCBSND) subject matter experts who will review and render a determination. Therefore, selecting the correct service type is key to receiving the most effective and efficient service from our authorizations team.
To assist with choosing the correct service type, we have created a guide, noted within Step 12 of the Predictal Process guide.