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Changes to Imaging and Sleep Management Programs for Medicare Advantage members

We're improving the management of imaging and sleep services for our Medicare HMO and Medicare PPO members in an effort to increase the quality and efficiency of these services. On January 1, 2018, we'll require prior authorization for all imaging and sleep services included in our programs. AIM Specialty Health (AIM) will manage authorizations. AIM has experience managing imaging and sleep services for our members, as well as for most other Blue plans with approximately 42 million lives under management across the country.

Medicare Advantage (HMO):
The imaging management program for Medicare Advantage HMO members will move to a full Utilization Management (UM) program for procedures that require a pre-service prior authorization. A UM program requires a Medical Necessity determination prior to the coverage of services. We'll continue to exclude certain provider groups in Massachusetts from the management process when those groups meet established criteria.

New for our Medicare HMO Blue members is a UM program for sleep services which will require a pre-service prior authorization and a Medical Necessity determination prior to coverage of services.

Medicare Advantage (PPO):
There are new requirements for Medicare PPO Blue members relating to the full Utilization Management (UM) program for both imaging and sleep services. Members are now required to get a pre-service prior authorization and a Medical Necessity determination prior to coverage of services from in-network PPO Providers.

If you have any questions, please contact your account executive.

Blue Cross Blue Shield of Massachusetts

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