Reminder: Providers responsible for obtaining preservice reviews for out-of-area Blues members prior to inpatient admissions

As we informed you in a March 2014 Record article, Blue Cross and Blue Shield Association’s Provider Financial Responsibility Mandate dictates that all participating facilities are financially responsible for obtaining an inpatient preservice review for out-of-area Blues members when required by the member’s plan. This requirement is effective July 1, 2014.

Here’s what participating facilities need to do:

• Obtain preservice reviews prior to admissions for all inpatient facility services when such a review is required under the member’s plan. Policy requirements for preservice reviews remain the responsibility of the home plan. The Medical Policy/Pre-Authorization router can be used to obtain preservice requirements for the plan.
• Facilities are required to notify the home plan within 48 hours of a change to the original authorization. Changes could include clinical complications resulting in a change to the admission type or days approved. 
• Facilities are required to request preservice review within 72 hours of an emergency or urgent care admission.
• Out-of-area Blues members cannot be held financially responsible for any inpatient facility services provided if a preservice review is required and not performed prior to the admission.
• Failure to adhere to the requirements of this mandate could result in a partial or full denial of the claim for the inpatient services.

Providers can use the Electronic Provider Access tool to request a preservice review. You can access the tool by going to bcbsm.com/providers and logging in. For complete details, see the article in the October Record.