NaviNet Medical Authorizations Participant Guide

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Prior Authorization Resources

Blue Cross Complete of Michigan's self-service tools are valuable resources that can assist you in providing the highest quality of care to our members.

NaviNet

Enter prior authorization requests, access member eligibility and status claims using the provider portal NaviNet.

By logging on to the Blue Cross Complete payer-provider portal  Navinet , you have the opportunity to:

• Receive news alerts in real time

• View Blue Cross Complete member information

• Submit authorization requests

• View gaps in care reports

• Check the status of claims

Go to NaviNet

NaviNet Guides

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NaviNet Medical Authorizations Participant Guide

Use the NaviNet Medical Authorizations Participant Guide (PDF) to learn more about using the NaviNet Medical Authorization system.

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NaviNet Medical Authorizations Frequently Asked Questions

Refer to the NaviNet Medical Authorizations Frequently Asked Questions (PDF) to review commonly asked questions.

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Care Gap Response Form Guide

The Care Gap Response Form Guide (PDF) contains detailed information for providers about how to use NaviNet to enter Care Gap resolution data online. This guide explains how to retrieve and report on specific Care Gap changes.

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Condition Optimization Program Provider User Guide

The Condition Optimization Program Provider User Guide (PDF) contains details about how providers access Condition Optimization Program workflow activities within NaviNet.

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NaviNet Basics

Visit NaviNet Basics if you have not yet enrolled or would like more information.

Prior Authorization Lookup Tool

Find out if a service needs prior authorization. Type a Current Procedural Terminology, or CPT, code or a Healthcare Common Procedure Coding System, or HCPCS, code in the space below to get started.

Important Notice

This tool provides general information for outpatient services performed by a participating provider. Prior authorization requirements also apply to secondary coverage.

The following services always require prior authorization:

• Inpatient services (elective and urgent)

• Codes not on the Michigan Medicaid Fee Schedule

If you have questions about this tool, a service or to request a prior authorization, contact Utilization Management at  1-888-312-5713 .

Contact your Blue Cross Complete account executive to receive the most recent prior authorization requirement updates.

Directions

• Enter a CPT or HCPCS code in the space below.

• Click Submit.

• The tool will tell you if that service needs prior authorization.

Disclaimer

The following attempts to provide the most current information for the Pre-Authorization Look-Up Tool. Please note that this information may be subject to change, and a Pre-Authorization is NOT a guarantee of payment. Payment is dependent on a number of factors, including but not limited to member eligibility on the date of service, coverage limitations and exclusions, provider contracts, and correct coding and billing for the services at issue. Blue Cross Complete reserves the right to adjust any payment made following a review of the medical records and determination of medical necessity for the services rendered. For additional details, or if you are uncertain that pre-authorization is needed, please see the Provider Manual on the Blue Cross Complete website.

Prior authorization forms and portal links

Utilization management authorization request

Download

Use the Utilization management authorization request form (PDF) to submit for prior, concurrent or retrospective review authorization requests.

Medication prior authorization request form

Download

Some medicines and benefits require prior authorization by Blue Cross Complete. Submit a prior authorization request using the Medication prior authorization request form (PDF).

Online Portals

To submit prior authorization requests electronically, please submit an electronic Prior Authorization through your Electronic Health Record tool software, or you can submit through any of the following online portals:

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CoverMyMeds

Go to CoverMyMeds

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SureScripts

Go to SureScripts

You must submit a request for a prior authorization for your patient. You must also submit an override of a drug restriction. Requests from pharmacies aren't accepted. For more information, view the pharmacy prior authorization request documentation guidance (PDF) .

Have questions about prior authorization?

How to submit authorizations electronically

Blue Cross Complete offers our providers access to  Medical Authorizations  for electronic authorization inquiries and submission. The  Medical Authorizations  portal is accessed through NaviNet located on the Workflows menu.

In addition to submitting and inquiring on existing authorizations, you will also be able to:

• Verify if  No Authorization is Required

• Receive  Auto Approvals , in some circumstances

• Submit  Amended Authorization

• Attach supplemental documentation

• Sign up for  in-app status change notifications  directly from the health plan

• Access a  multi-payer Authorization log

• Submit inpatient concurrent reviews online if you have Health Information Exchange (HIE) capabilities (fax is no longer required)

• Review inpatient admission notifications and provide supporting clinical documentation

Healthcare common procedure coding system medications

A prior authorization for healthcare common procedure coding system medications is required before they are covered by Blue Cross Complete. Click the  HCPCS PA List (PDF)  for a list of codes that require prior authorization.

Non-emergency outpatient diagnostic imaging resources

Effective May 1, 2022, Blue Cross Complete will require prior authorization from Evolent, formerly National Imaging Associates, Inc., for most non-emergency outpatient diagnostic imaging services. Providers are encouraged to use resources below, visit  RadMD.com  or call Evolent at  1-800-424-5351 .

• Medical Specialty Solutions Utilization Review Matrix 2022 (PDF)

List of all CPT codes Evolent manages on behalf of Blue Cross Complete

• Medical Specialty Solutions Prior Authorization Checklist (PDF)

Required information to have ready before logging on to RadMd.com or calling Evolent

• Medical Specialty Solutions Quick Reference Guide for Providers (PDF)

• Frequently Asked Questions for Providers (PDF)

• Medical Specialty Solutions Program Tip Sheet for Prior Authorization of Cardiac Services (PDF)

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