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Enhancements to Imaging and Sleep Management Programs

We’re improving the management of imaging and sleep services for our Fully Insured and ASC HMO/PPO accounts to increase the quality and efficiency of these services. On June 1 2017, we’ll require prior authorization for all imaging and sleep services included in our management programs. AIM Specialty Health (AIM) will manage authorizations. AIM has experience managing imaging and sleep services for our HMO members, as well as for most other Blue plans with approximately 42 million lives under management across the country.

For our HMO members
The imaging management program, which has been in place since 2005, 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.

Your sleep management program, which has been in place since 2013, already requires authorization before the service, and so is unchanged. All provider groups in Massachusetts participate in this process.

For our PPO members
New requirements for pre–service authorization will go into effect for in–state and out–of–state services. As a result of this change, if out–of–state PPO members don’t obtain pre–service authorization, they’ll be financially responsible for the cost of services. As with our HMO programs, some Massachusetts provider groups may be excluded from the management requirements for imaging, and all provider groups are required to participate in the sleep management program.

Educational Member Resources
To help you better inform your members, we’ve developed a helpful fact sheet that explains the enhancements to our Imaging and Sleep Management Programs.

You can access it here.

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

Blue Cross Blue Shield of Massachusetts

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