BCBS Medically Unnecessary Services

Effective July 14, 2014 BCBS IL has a change in policy for services deemed to be medically unnecessary or medically unproven (experimental and/or investigational). These services will no longer be considered patient responsibility upon denial.  These services will be denied with a message specifying that the patient is not financially responsible for the charges.

What items are considered medically unproven?  Interferential current stimulation, pneumatic traction and spinal uploading devices in any setting, many types of allergy testing, traction devices for use in the home, kinesiology, spray and stretch technique for myofascial pain, intermittent motorized traction, intersegmental traction, methods of mechanical massage, craniosacral therapy, hydrotherapy beds, kinesio taping, and low level laser are among the many elements that are not covered by BCBS. 

In order to charge the patient for these non-covered services, the patient must sign and date an authorization form that states the member has been informed prior to the services being rendered, that the services are no covered.  It must include the total cost of the services and a confirmation that the member accepts all financial responsibility.  

BCBS IL Medically Unnecessary

 

Effective July 14, 2014 claims submitted to BCBSIL for services deemed to be medical unnecessary, medical unproven, experimental or investigational will be denied with a message state the member will not be financially responsible for the charges.  If you are aware that a proposed service will meet the above criteria, you must obtain a written discloser/authorization from the member informing them that the services are not covered by BCBSIL and the patient is financially responsible for the services.  This must be done PRIOR to the services being rendered, must include the total cost and confirmation that the member accepts the financial responsibility.

 

Medically unnecessary services include intersegmental traction, interferential e-stim, kinesiology, hydrotherapy, knesio taping and some forms of massage therapy. 

 

 

BCBS IL Change in Massage Therapy Policy

Effective September 1, 2014 providers billing for the services of a licensed massage therapist (LMT) will face new rules from Blue Cross Blue Shield of Illinois.   Services rendered by a massage therapist can no longer be billed under the supervising provider’s national provider identifier (NPI). 

 

Licensed massage therapists must apply for a National Provider Identifier (NPI).  The link for obtaining an NPI is here.   Once the LMT has obtained an NPI, providers must update their provider information online using the BCBSIL system.  The link for the update is here

 

PPO providers should complete the provider update process as early as possible to prevent delay or denial of claim services. 

 

BCBS IL states that beginning September 1, 2014 all services performed by an LMT must

a.) be within the scope of practice for an LMT

b.) meet medical policy criteria for medical necessity and

c.) be part of a treatment plan created by a licensed qualified provider. 

 

All therapy services must be delivered under a written plan of care and must include measurable goals that restores functional impairment.  Goals should be specific, e.g. “Patient’s ROM deficiency will improve from X to Y during the next 30 days of care”.  Generic goals may cause the service to be considered not medically necessary.

 

Massage services delivered by an LMT will received a reduced reimbursement.