Payer Space: BCBS Medicare Advantage

BCBS Medicare Advantage

🎯To identify the plan type/location:

Use the member services tool to search by the 3-letter prefix of the plan ID number:

• https://www.bcbs.com/member-services
• Note: Do not search by ZIP code.

✔️ ELIGIBILITY, COVERAGE & BENEFITS

-          Run eligibility on Availity.com

-          Must meet MDCR criteria to cover home health services

-          Must be homebound

In-State plans only (verify via phone call if an out of state plan):

-          Primary Care Clinical Referral not required for in-state plans.

-          Visit limits are based on medical necessity and physician orders; no annual visit limits.

📜 PRIOR AUTHORIZATION

Essentials to know:

• BCBS Medicare Advantage always requires prior authorization for all services.
• As of 3/17/26, prior authorization can only be submitted up to 14 days after the date of service. However, prior auth should requested as soon as possible (but must include specific documentation described below to be successfully authorized).
• Uses G codes. See table in Appendix B.
• Request Q codes with each prior auth request. See instructions.
• Make sure to request therapy assistant codes (PTA/COTA) if PT/OT is provided and therapy assistants may be used.
• Submit authorization requests on Availity.com

Documentation to submit with prior auth requests:

Follow these steps:

1. When you have identified a prior authorization request is needed for a client's services (typically prompted by workflow) locate the order(s) in HCHB which ordered those services.
2. Identify the order(s) status by following these steps.
   1. When processing initial eligibility for a new SOC:
      • There will be no order entered yet and the prior auth will need to be requested after the SOC visit.
      • When processing initial authorization workflow, enter a pending auth with enough visits to allow the initial SOC and Evals to be scheduled.
      • After the SOC is completed, check the status of the plan of care (485) order and continue with the steps below.
3. Check on the order status daily until it is approved.  It is very important we wait to use the order until it is in Approved status.
   • A verbal order is written by the clinician after communication with the client's physician/NPP office. In most cases, this is in conjunction with the Start of Care, Recertification, Evaluation, or other visit at which additional services are determined to be necessary.
   • We must wait until this verbal order is in Approved status to proceed with an authorization request.
   • There is no circumstance in which an unapproved order is appropriate to use as supporting clinical documentation for an authorization request.
4. After the order is approved, you may proceed.
5. If there are multiple orders needing auth requested:
   1. Ensure all orders are in the same status. Orders in the same status with visits in the same episode may be combined on one authorization request.
   2. If the orders are in different statuses:
      • Create separate auth requests according to the differing order(s) statuses, requesting the ordered visits separately.
      • In the payer setup, create a separate pending authorization for each separate request, as each request will have different auth numbers assigned.
      • Example: If SN visits are ordered on the Plan of Care (485) and PT is ordered in the Add-On Discipline (AOD) order, and one of these is approved and one is not, they should be requested separately. Likewise, if one of the orders were approved and signed, but the other was approved but unsigned, these should also be requested separately and set up as separate pending authorizations.
6. Compile the following supporting documentation needed for the prior auth request.
   1. The approved verbal order(s). See instructions.
   2. (If the orders are unsigned) A customized prior authorization letter with the COP verbiage.
      • Create the letter by following these instructions.
   3. The OASIS visit note(s) associated to the order(s) tied to the request.  For example:
      • If requesting visits ordered on a 485, include the admission (e.g. RN00) or Recertification (e.g. RN02) visit note.
      • If requesting visits ordered on an Add-On Discipline order (AOD), include the Evaluation  (e.g. PT01, OT01, ST01) visit note.
      • If requesting visits ordered from a Resumption of Care order (ROC), include the Resumption of Care (e.g. RN15) visit note.
   4. (If for the initial admission visit) The DC orders/F2F clearly showing the ordered home health services with a physician/NPP signature.
7. Label the saved PDF's with a description of what the document is specifically. For example:
   1. Client-last-name Plan of Care Verbal Order
   2. Client-last-name Add-On Discipline Verbal Order
   3. Client-last-name Prior Auth Request - Letter
   4. Client-last-name RN OASIS Admission Visit
   5. Client-last-name PT OASIS Evaluation Visit
8. On availity.com, create the new authorization request.
   1. Note that any information added in the comment box is not viewed by the reviewers; do not add information in that area.
9. When you reach the final page where you add the supporting documentation. If including the customized letter which is needed when the order(s) is not signed, include this as the first attachment.
10. Submit the prior auth request after all steps are complete.

APPENDIX A

How to identify the correct Q-code for the required service location authorization:

1. First, identify the Service Location type.
   1. Navigate to the client referral via Clinical Input
   2. View the Demographics Tab.
   3. Scroll down to the Service Location and identify the Service Location Type.

The service location type and corresponding Q-code will be one of the following:

2. Request authorization via Availity for the Q code specific to the client’s Service Location type according to the following directives:
   1. A quantity of 2 authorization of the Q code is needed for each episode. This is because as each episode will usually have two 30-day bill periods. Each bill period uses a quantity of 1 from the authorization for the service location Q-code.
   2. When requesting the auth, select the Q code specific to the client’s location as determined by using the table above (Q5001, Q5002, or Q5009).
   3. As in the example below:
      1. Select the authorization code.
      2. From Date & To Date: Use the date range of the episode.
      3. Quantity type: Units.
      4. Quantity: 2 per episode

3. After requesting the authorization, save a PDF record of the submitted authorization request in the client’s chart under the Auth Request attachment type.

APPENDIX B