OrthoNet Preauthorization FAQs
As ICS members are probably aware, Blue Cross Blue Shield of Illinois (BCBSIL) has begun implementation of its utilization management program requiring many providers to obtain preauthorization for physical medicine services. BCBSIL has classified providers into “tiers” requiring various levels of preauthorization and has contracted with OrthoNet to review provider requests for preauthorization.
Consistent with its policy of keeping members as informed as possible, the ICS is sharing this updated information that was provided by BCBSIL and Orthonet during a training session in December 2013. We will attempt to update these FAQs as the actual process occurs. The ICS wishes to clarify that it is sharing this information so that ICS members will have the most current information released by BCBSIL and OrthoNet. However, by conveying this material, the ICS does not intend to render an on opinion about or imply agreement with the process. Providers can find more information about the program by visiting http://www.orthonet-online.com/dl_BCBSIL.html.
Is there a quick reference guide for this new program?
Yes. Chiropractic physicians can access OrthoNet’s guide here: http://www.orthonet-online.com/forms/BCBSIL/BCBSIL_Chiropractic_Reference_Guide.pdf.
How do I request benefit preauthorization?
According to OrthoNet, doctors are required to use the Chiropractic Request Form (CRF) which is available on the OrthoNet website (http://www.orthonet-online.com/dl_BCBSIL.html) or by calling 1-888-875-9480. OrthoNet claims that faxing the form to 1-888-875-9503 will be the quickest method and that their goal is to respond within 2 business days. You need only send the CRF unless OrthoNet specifically requested your evaluation or treatment notes. Make sure that the complete provider and member information is filled out on the form (top portion), and include your office fax and phone numbers in the event OrthoNet needs to contact you.
Does the CRF replace my documentation or office specific forms?
No. OrthoNet states that the intent of the Chiropractic Request Form is only to summarize your findings of the history and physical examination required by Orthonet for preauthorization. The ICS recommends you maintain professionally accepted standards of documentation, in addition to the CRF.
Is Outcomes Assessment Testing required for payment?
No, but OrthoNet appears to encourage it. Field 9 on the CRF allows for Outcome Assessment scores. Choose one primary form type only. If using SF-12/36 or similar forms you may enter up to two scores (mental & physical).
Where can I find BCBSIL medical policies?
www.bcbsil.com under the “Provider” tab.
Can a treatment be performed on the same day as an initial evaluation?
Yes. According to OrthoNet, this will be counted as one combined visit. As a reminder, this pre-authorization program only applies to physical medicine codes.
Where do I send my claims?
OrthoNet states there is no change to the claims submission process and that providers should continue to submit claims to BCBSIL in the usual manner.
Where do I send my claim appeals?
OrthoNet states there is no change to the claims appeal process, and that providers should continue to submit claims appeals to BCBSIL in the usual manner.
What happens if I do not preauthorize care (after my allotted physical medicine visits) with Orthonet?
According to OrthoNet, you will be asked to submit full medical records before your claims will be processed. Failure to submit requested records will result in a denial.
Does preauthorization guarantee payment for services rendered?
No. As has previously been its policy, BCBSIL states that patient eligibility, medical necessity, contractual agreements, and a number of other factors are figured into payment determination.