Beginning in July, PPO inpatient admission requests submitted through e-referral could be subject to clinical review

Starting July 9, 2018, inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial PPO members submitted through e-referral could be subject to clinical review. It’s a process that our facilities already follow for Medicare Advantage PPO inpatient acute care admissions and certain other members.

Clinical reviews like this become necessary as customers look for ways to reduce the amount they spend on medical services and as we try to consistently apply utilization management programs. For example, Blue Care Network, BCN Advantage^SM and Medicare Advantage PPO all have full inpatient review programs at Michigan hospitals.

These reviews also help us ensure that the patient stays are appropriate and billed correctly based on the patient’s diagnosis and condition.

With this inpatient review program, select facilities must submit medical inpatient stays through e-referral, and the requests could be reviewed and approved or pended for review by a clinician.

Additionally, behavioral health authorization requests and clinical reviews will continue according to the current process with the assigned behavioral health management vendor. However, inpatient admission authorization requests processed through New Directions** will be subject to full clinical review from the first day of admission and subject to non-approval. 

We’ve notified the affected facilities if their inpatient medical and behavioral health admissions require this new clinical review process.

If you’re not already familiar with e-referral or how the process works, contact your provider consultant for more information.

**New Directions is an independent company that provides behavioral health services for Blue Cross Blue Shield of Michigan.