Prior authorizations for post-acute care

For services beginning on November 1, 2022, prior authorization requests for admission to or concurrent stay in a skilled nursing facility (SNF), an inpatient acute rehab facility (IRF), or a long-term acute care hospital (LTACH) will be reviewed by myNEXUS* services for Medicare Advantage individual, group retiree solutions (GRS), and dual-eligible plan members. Through this program, myNEXUS clinicians will collaborate with members, caregivers, and facility care managers/discharge planners to provide transition planning as well as the pre-service and concurrent review authorizations of post-acute care services. The goal of this program is to support members through their recovery process in the most appropriate, least restrictive environment.

 

How to submit or check a prior authorization request:

For SNF, IRF, or LTACH admissions, myNEXUS will begin receiving requests through the NexLync website on Sunday, October 30, 2022, and by telephone or fax on Monday, October 31, 2022, for members whose anticipated discharge date is November 1, 2022, or after. Concurrent stay review requests for members admitted to SNF, IRF, or LTACH facilities prior to November 1, 2022, should be directed to Empire BlueCross BlueShield (Empire).

 

Providers are encouraged to request authorization using NexLync. Visit https://portal.myNEXUScare.com/home to get started. You can upload clinical information and check the status of your requests through this online tool seven days a week, 24 hours a day. If you are unable to use the link or website, you can call the myNEXUS Provider Call Center at 844-411-9622 during normal operating hours from 7 a.m. to 7 p.m. CT, Monday through Friday, or send a fax to myNEXUS at 833-311-2986.

 

Please note: myNEXUS will not review authorization requests for durable medical equipment (DME), ambulance, and other related services that do not fall under Medicare-covered home healthcare services, such as home infusion, hospice, outpatient therapy, or supplemental benefits that help with everyday health and living such as personal home helper services offered under essential/everyday extras.

 

To learn more about myNEXUS and upcoming training webinars, visit www.myNEXUScare.com/Anthem or email Provider_Network@myNEXUScare.com.

 

What if I need assistance?

If you have additional questions, please call the myNEXUS Provider Call Center at 844-411-9622. If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website (https://www.empireblue.com/medicareprovider) for up-to-date contact information or call Provider Services via the number on the back of members’ ID cards.

 

* myNEXUS is an independent company providing health management services on behalf of Empire BlueCross BlueShield.

 

NYBCBS-CARE-003638-22 July 2022