|
October 2017
Here’s what you need to know about Blue Cross inpatient authorization requirements
Inpatient admission authorization requests for Blue Cross Blue Shield of Michigan commercial PPO and Blue Cross Medicare Plus BlueSM PPO must be submitted through e-referral, effective July 31, 2017. The only exceptions are sick or ill newborns and gender reassignment authorization requests, which must be faxed.
The application of clinical criteria is required in some cases to receive authorization for Blue Cross inpatient stays. For more information, see the Blue Cross Authorization Requirements & Criteria page on the e-referral site.
Members with Medicare Plus Blue or URMBT coverage
Concurrent review will occur for all inpatient admissions for members with Blue Cross Medicare Plus Blue PPO coverage and those with Blue Cross commercial PPO coverage through the UAW Retiree Medical Benefits Trust. Following is additional information for submitting inpatient requests for these members:
- Facilities and providers should request an appropriate number of days when submitting their authorization request, based on the member’s diagnosis and clinical presentation.
- Requests for additional days must be submitted through e-referral and must include clinical updates.
- If the member is discharged before the last covered day, a discharge date should be entered in e-referral. The discharge date and the total number of days the member was inpatient can be added to e-referral as a note. For instructions on how to do this, see the e-referral User Guide. Go to the Submit an Inpatient Authorization section, and review the Create New (communication) instructions.
Requirements for Blue Cross commercial and Medicare Plus Blue
Following are details about submitting authorizations for various types of services for members with Blue Cross commercial and Medicare Plus Blue:
|
|
|
|
|
Type of service |
Authorization type |
Admission date |
Length of stay – initial request |
Length of stay – extension request |
Elective surgical inpatient admission |
Inpatient |
Enter admission date |
3-5 days** |
5-7 days |
Inpatient medical admission*** |
Inpatient |
Enter admission date |
3-7 days** |
5-7 days |
Newborns |
Must be submitted by fax to 1-866-411-2585 |
Gender reassignment**** |
Must be submitted by fax to 1-866-411-2585 until further notice |
Observation |
Not required for Blue Cross |
Maternity admission |
Not required for Blue Cross |
**Length-of-stay request should be appropriate for treatment type.
***Behavioral health and substance abuse requests that require an acute inpatient admission must be submitted with a medical diagnosis.
****Gender reassignment requests must be submitted with a medical diagnosis.
Note: The Federal Employee Program® requires all gender reassignment surgeries obtain prior approval for the surgical procedure and precertification for the inpatient admission.
| 
