New Prior Authorization Procedures by eviCore

As of June 1, 2017 eviCore was selected by Blue Cross and Blue Shield of Illinois to manage the inpatient post-acute care prior authorization process for skilled nursing, inpatient rehabilitation, and long term care facilities. Blue Cross and Blue Shield members that are enrolled in the following programs will require their prior authorization from eviCore.

Medicare

• Blue Cross Medicare Advantage (PPO)™

Medicaid

• Blue Cross Community MMAI (Medicare-Medicaid Plan)™
• Blue Cross Community (ICP)™
• Blue Cross Community Family Health Plan (FHP)™

As a best practice providers should verify both member eligibility and plan enrollment prior to admission. Member eligibility can be performed online at www.availity.com or by calling the number listed on the back of the insurance card.

In addition the beneficiary’s discharging hospital is responsible for submitting the initial post-acute care admission request. Facilities should coordinate this process with the discharge planner at the referring hospital to ensure that it is completed. The admitting facilities are responsible for submitting the subsequent authorization requests through the course of the resident’s stay. The only exception to this process is if the post-acute care facility and hospital share the same Tax ID number or National Provider Identification (NPI). eviCore is estimating a 24-48 hour response time to prior authorization requests.

eviCore is suggesting that post-acute care facilities submit their prior authorization request along with clinical documentation to support medical necessity 72 hours prior to the last covered day to allow time for the NOMNC (Notice of Medicare Non-Coverage) to be issued. eviCore will be issuing the NOMNC form to the provider and the provider is responsible for having it signed and returned to eviCore. Remember, even though a different entity is preparing the beneficiary notice, it is ultimately the responsibility of the nursing facility that it be issued properly and timely. The facility will be held provider liable, not eviCore, if there is an invalid notice or no notice given. The excuse that eviCore did not provide the notice or that they did not properly complete the notice will not waive the facility of responsibility.

For skilled nursing facilities eviCore has stated that the initial prior authorization will cover a three business day period. The subsequent prior authorizations will be issued and cover a seven calendar day period. We have also been seeing that eviCore is not approving retroactive prior authorizations. If the hospital does not submit the initial prior authorization before admission to the SNF, the initial days of the stay will be not be covered. Also, since the initial prior authorization only covers the first three business days, it is important that the facility begin the subsequent authorization within a day of admission to allow time for processing.

There are four options available for providers to utilize for the submission of prior authorization requests.

1. Fax clinical documentation to 855-826-3725, one resident per fax.
2. If you currently use Allscripts, you may submit your requests via Allscripts to eviCore.
3. By phone at 855-252-1117.
4. The eviCore post acute care portal.

Working closely with the discharging hospital has always been an important part of the admission process to the nursing facility, but now with the new prior authorization requirements it is even more vital. Be sure your admissions staff stays in close communication with the discharging hospital to ensure the paperwork is completed.