Follow Centers for Medicare & Medicaid Services Guidelines for Appointment Wait Time Standards

Ensure timely access to care for our members by following CMS guidelines for appointment wait time standards for behavioral health services, routine primary care and non‑urgent specialty care.

Out‑of‑State Care Beyond Contiguous Counties No Longer Covered Benefit for Individual and Family Market Members

Starting Jan. 1, 2025, members with Blue Preferred PPO^SM and Blue Focus POS^SM Individual and Family Market benefit plans purchased on or off the marketplace exchange will no longer have covered benefits for non‑urgent and non‑emergent care outside of Montana and beyond its surrounding border counties when adequate care is available in‑state and or in its contiguous counties. This change does not apply to members with group coverage.

Learn How to Submit Photos to Support Utilization Management Requests

Use our electronic processes to submit photos to support prior authorization and recommended clinical review requests. Secured email and online options are preferred instead of faxing photocopies.

Accurate Category II Codes May Help Identify Gaps in Care

Using the proper Current Procedural Terminology (CPT^®) Category II codes on claims can help streamline your administrative processes and ensure gaps in care are closed. We developed a coding reference for several quality measures that you can access in Availity^® Essentials.

Cultural Awareness Webinars: Earn No‑Cost Continuing Education Credit

We offer a suite of self‑guided courses that provide cultural awareness training and continuing education credit. Webinars include chronic disease management and improving adherence in diverse populations.

Funds to Be Recouped on Some Medicare Advantage Hospital and Ancillary Claims

We recently identified that some Medicare Advantage claims were paid incorrectly to hospitals and ancillary providers. You’ll receive a letter if you have any impacted claims. Learn more about our recoupment process.

Prior Authorization Changes for Government Programs

Effective Jan. 1, 2025, we’re changing prior authorization requirements for Medicare Advantage members to reflect new, replaced or removed codes.

Preferred Drugs to be Recommended Through Enhanced Prior Authorization

When submitting prior authorization requests for certain drugs, you’ll receive recommendations for comparable preferred drugs, as of Jan. 1, 2025. This process can improve access to more affordable care for our commercial and individual members.

Pharmacy Program Quarterly Update – Part 1

Some changes were made to our drug lists, including revisions, exclusions, dispensing limits and utilization management changes. Learn about these and other pharmacy program updates.

Coding and Compensation Policy Updates

You can access new or revised clinical payment and coding policies in Availity Essentials through the Plan Documents Viewer application, in the category Coding and Compensation Policies. These policies provide billing, coding and documentation guidelines. Visit Availity regularly to ensure you’re up to date on any changes or new policies.

Medical Policy Updates

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month under the Standards and Requirements tab. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.