Providers could be financially responsible for not obtaining preservice reviews for Blue Cross members prior to inpatient admissions

As we wrote in a July 2014 Record article, all participating facilities are financially responsible for obtaining an inpatient preservice review when it’s required by the member’s plan. This requirement, part of the Blue Cross and Blue Shield Association Provider Financial Responsibility Mandate, became effective July 1, 2014. 

Effective Jan. 1, 2016, Blue Cross Blue Shield of Michigan is amending its inpatient authorization reimbursement policy for all inpatient admissions that require preservice review as part of this mandated policy. Participating facilities that do not obtain a required preservice review prior to the admission will be financially responsible if an authorization cannot be obtained within 60 days of the date of the admission.

If the retro service review is not obtained within 60 days from the date of the patient’s admission, our contracted reimbursement for the claim will be reduced to 70 percent of the allowed amount, with a 30 percent provider sanction.  This reimbursement policy applies to inpatient facility claims for both Blue Cross Blue Shield of Michigan members and members enrolled in out-of-state BCBS commercial contracts processed through BlueCard.

This policy also applies to Blue Cross Blue Shield of Michigan Medicare Advantage PPO members for inpatient claims with the exception of admissions to skilled nursing facilities, long-term acute care hospitals and inpatient rehabilitation. Blue Care Network is excluded from this policy.

For services provided to out-of-area members, the home plan’s authorization guidelines apply.

Keep the following in mind:

• Facilities should complete the required preservice review prior to the admission of any Blue Cross Blue Shield of Michigan member or a Blue member enrolled in an out-of-area plan.
• Facilities should continue to use our current processes to request a preservice review for Michigan members to include:
• Using our electronic prenotification process for all acute care admissions for both Blue Cross Blue Shield of Michigan members and BCBSM Medicare Advantage members who reside in Michigan
• Contacting Blue Cross or the required mental health provider for medical rehabilitation, skilled nursing, psychiatric or substance abuse admissions
• Facilities should contact the member’s home plan by calling 1-800-676-2583 for the required authorization or using the Electronic Provider Access tool. See the October 2013 Record article for information on the tool.
• Facilities are required to notify the home plan within 48 hours of a change to the original approved 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.
• Facility claims for inpatient admissions billed to Blue Cross Blue Shield of Michigan without the required authorization to admit the patient into the facility will continue to be rejected as they are today.
• Blue Cross Blue Shield of Michigan does not manage the retroactive preservice review process of other Blue plans and cannot ensure the timeliness or the decision to allow a retroactive service review. We will, however, let other Blue plans know that a 30 percent sanction can be applied to out-of-state claims if the required preservice review is not performed or the retroactive service review has not been obtained. For Medicare Advantage members, the 30 percent sanction will only apply to inpatient acute care hospital claims.
• The current policy for contacting the member’s home plan to request an appeal for an adverse preservice review (authorization) decision — or to appeal a retroactive service review — remain in place. You can reference the BlueCard chapter of any of our online provider manuals for additional information on appeals.
• Members are held harmless for any rejected claims or the 30 percent provider sanction.

If additional information about this process needs to be communicated, we will include it in a future Record article.