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.Section 1: Plan notification and clinical review requirementsPlan notification alerts BCN to a scheduled service and is used for claims processing purposes. BCN does not perform clinical reviews on servicesthat require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical review is conducted forbenefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at least 14 days priorto services being rendered. Note: This list is not all-inclusive. See also the notes at the end of Section 1. In addition, authorization of a service byBCN Care Management based on the clinical information provided does not guarantee payment. When the claim for the service is submitted, it may besubject to edits including, but not limited to, diagnosis, frequency and dose. The outcome of those edits may override the initial authorization.ServiceIntensive outpatient therapy (mental health/ substance abuse)Kalbitor ® §Krystexxa TM §RequirementsBenefit / clinical review is required for all members.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Laboratory services, genetic tests Benefit / clinical review is required for all members. Must send requests to JVHL at 1-800-445-4979.Lucentis ® §Makena TM §Maternity: up to 48 hours following routinedelivery / 96 hours following C-sectionMental health therapyMRI of breastNeuropsychological / psychological testingfor bariatric surgeryNplate ® §Orthognathic surgeryPain management with epidural or facetjoint injectionsPartial hospitalization (mental health /substance abuse)Physical / occupational / speech therapy -autism treatmentPhysical / occupational / speech therapy -unrelated to autism treatmentProlastin ® §Prolia TM §Proton beam therapyProvenge ® §Pulmonary rehabilitationRadiology high-tech procedures2015 BCN Referral and Clinical Review ProgramFor all services, noncontracted providers and providers who are not part of the designated network associatedwith the member's plan must obtain clinical review from BCN Care Management.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Plan notification is required for all members, including those whose coverage allows self-referrals.Benefit / clinical review is required for all members through BCN Behavioral Health.Benefit / clinical review is required for all members.Plan notification is required for all members.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Benefit / clinical review is required for all members.Benefit / clinical review is required for all members. Must complete the appropriate pain managementquestionnaire.Benefit / clinical review is required for all members.The provider is responsible for verifying whether each member has autism benefits and, if so,how they are managed and what the clinical review requirements are. In general, benefit / clinicalreview is not required for members whose autism benefits are managed separate from theirmedical benefits. It may be required for members whose autism benefits are managed as part oftheir medical benefits. When clinical review is required, those requests are handled by BCN CareManagement. Refer to the e-referral Autism page for additional information.Benefit / clinical review is required for all members. Contact Landmark Healthcare and see additionalinformation on Outpatient PT-OT-ST Management Program.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Benefit / clinical review is required for all members.Prior authorization / clinical review is required for all members except those with BCN Advantagecoverage.Benefit / clinical review is required for all members.All BCN-participating freestanding diagnostic facilities, outpatient hospital settings, ambulatorysurgery centers and physician’s offices that provide MRI, CT, nuclear medicine and nuclearcardiology are required to visit www.carecorenational.com or call 1-855-774-1317 for clinical review.Refer to BCN's e-referral Radiology Management Program Web page for additional information.Reclast ®Remodulin ® §See zoledronic acid.Prior authorization / clinical review is required for all members.Page 3 of 11Revised April 1, 2015