BCBSM is denying claims for exceeds authorization when authorizations are not used up. For example, AIM authorizes 6 treatments, the claim is submitted by NDC where the same HCPCS code can appear more than once on a claim. Claims are processed without a problem the first couple of times, then denials are received stating you have exceeded your authorization limit. Why? This is occurring because the BCBSM system is processing each claim line as an authorized treatment day. You are left trying to contact AIM for additional authorizations or appeal your claims.
This problem initially became apparent with drugs such as Vectibix, Zirabev, and Kadcyla, however, we’ve recently learned that this could happen on any drug where you use multiple vials or bill waste on a separate line.
Working with MSHO, BCBSM has been able to uncover the system issue and is currently working on a fix. In the meantime, BCBSM has agreed to manually process any claim denial for this system error MSHO members have received. You do not have to appeal these claims or contact AIM for additional prior authorizations.
Is this happening to you? What you need to do to have your claims manually addressed:
If you have any questions, please contact MSHO's Senior Reimbursement Consultant, Michelle Weiss at email@example.com.