Additional changes to BCN process for requesting peer-to-peer review of non-behavioral health cases

We're making additional changes to the process of asking for a peer-to-peer review of a denied authorization of a non-behavioral health service for BCN HMO^SM (commercial) or BCN Advantage^SM members.

The request for a peer-to-peer review:

• Must be submitted within the time frame available for filing an appeal for that determination. Once the appeal time frame has expired, you can no longer request a peer-to-peer review.
• Cannot be submitted if a provider appeal of that denial has already been submitted
• May be submitted only for denials based on medical necessity
• Cannot be submitted for a denial of a member's appeal or grievance

We have outlined these requirements - and additional information about them - in Section 1 of the document How to request a peer-to-peer review with a BCN medical director.

These requirements apply to authorization requests for both inpatient and outpatient services. They are in addition to the change we communicated in December 2018, which was that you must use the Physician peer-to-peer request form (for non-behavioral health cases) to submit the peer-to-peer review request.

You can access both documents - the description of the process for submitting a peer-to-peer review request and the form - on this website by completing the following steps:

1. Click BCN.
2. Click Authorization Requirements & Criteria.
3. Look under the "Referral and authorization information" heading.

Posted: March 2019
Line of business: Blue Care Network