BCN Referral and Clinical Review Program - e-Referral

Changes from previous publication are identified by a Blue Dot and explained on page 10 of this document.2015 BCN Referral and Clinical Review ProgramBlue Dot Changes to the2015 BCN Referral and Clinical Review ProgramService or TopicDrugs covered under themedical benefit that requireprior authorization / clinicalreviewChange DescriptionEffective April 1, 2015, services associated with the drugs listed below require prior authorization / clinical reviewfor all members except those with BCN Advantage coverage.• Aralast NP • Elaprase • Fabrazyme • Ilaris • Soliris • Zemaira• Cerezyme • Elelyso • Glassia • Prolastin • VprivFor services associated with procedure code J9999, all requests require prior authorization / clinical review for allmembers, effective April 1, 2015.TransplantsBCN Advantage HMOConnectedCareBlue Cross Metro Detroit HMOBlue Elect Plus Self-ReferralOptionRadiology high-techproceduresThe list of procedure codes that require clinical review is now divided into two lists: one for services not involvingdrugs covered under the medical benefit (titled "Sec. 3") and the other for services involving drugs covered underthe medical benefit (titled "Sec. 4").Effective May 1, 2015, for transplant services that require clinical review, members must be directed to a BlueDistinction Center+ for Transplants.References to BCN Advantage HMO Local are removed. Information about BCN Advantage HMOConnectedCare is added. This product is effective Jan. 1, 2015, and has its own designated provider network.For BCN Advantage HMO ConnectedCare members, services rendered by providers outside of the networkdesignated for that product require clinical review.Information about to the Blue Cross Metro Detroit HMO product is added. The Blue Cross Metro Detroit HMOproduct, which is effective Jan. 1, 2015, has its own designated provider network. Standard referral and clinicalreview requirements apply.The information about Blue Elect Plus Self-Referral Option requirements is clarified. Members who have coveragethrough Blue Elect Plus Self-Referral Option may choose to self-refer to any provider within or outside of thestatewide BCN HMO network provider without need for a referral, but clinical review requirements do apply forcertain services and some services are covered only if rendered by an in-network provider. Providers should go toweb-DENIS to get full information on the requirements for each service.The requirements for radiology high-tech procedures are clarifed. All BCN-participating freestanding diagnosticfacilities, outpatient hospital settings, ambulatory surgery centers and physician’s offices that provide MRI, CT,nuclear medicine and nuclear cardiology are required to visit www.carecorenational.com or call1-855-774-1317 for clinical review. Refer to BCN's e-referral Radiology Management Program Web page foradditional information.Page 10 of 11Revised April 1, 2015