Blue Cross Blue Shield of North Dakota (BCBSND) wants to inform providers of a change impacting the review of Positron Emission Tomography (Pet) Scans.
Effective Dec. 15, 2023, BCBSND will move this service from a pre-service review to a post-service review. By moving this to a post-service claim review, it will allow providers to move forward with their treatment plan without waiting for a response from pre-service review. It also allows providers to attach additional clinical documentation that may not have existed or been available during the pre-service timeframe.
What does this mean for providers?
- Providers will no longer need to submit a prior authorization/precertification request for PET scans. If a prior authorization is submitted, it will be cancelled without review.
- Providers can provide the service and submit the claim. Once the claim is received, medical records and clinical documentation will be requested for a medical necessity review to take place.
- An exception to the post-service medical necessity review is if a previous prior authorization request was approved BCBSND will not review it post service and process according to the approval.
- For previous pre-service requests that were denied, additional medical necessity review will occur once the claim is submitted.
- Any current pended pre-service PET scan requests, waiting for clinical documentation, will continue to be reviewed accordingly. The above bullets will apply based on the final determination.
- As a reminder, when submitting documentation to BCBSND ensure to include the BCBSND request for information letter or use our Medical Record Submission form found on our website.
- It is important to thoroughly document patient information and findings within the medical records. Providers will also want to ensure they are sending all applicable documentation when the information is requested by BCBSND.
- Claims that do not meet medical necessity criteria will continue to deny as provider liable, as they do today. Members who have an out-of-state plan may be liable for non-covered charges.
- This process change is based on claim processing date, not date of service. If you have a member with a date of service prior to 12/15/2023, a post service medical necessity may be completed.
Standard appeal rights will be available for post-service claim determinations. Appeal information can be found here.
This change impacts procedure codes 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492, A9526,78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, A9591, A9595, A9602, A9800, G0219, G0235, and G0252. Please note, these codes are subject to change at any time. For current information be sure to utilize the criteria in the applicable BCBSND published policy prior to rendering the service. Policies can be found by using the search function of www.bcbsnd.com or by going directly to the medical policy webpage.
Please note, member booklets are in the process of being updated, so may not reflect this change until a later date.
This applies to the BCBSND Commercial line of business only. It will not apply to Medicaid Expansion, Comprehensive Health Association of North Dakota (CHAND), or the Federal Employee Program (FEP).
Questions?
If you have questions regarding policy criteria, benefits, claims or other PET scan related inquiries, contact the phone number on the back of the member’s ID card.
