Reminder: Inpatient admission requests submitted through e‑referral may be subject to clinical review

Inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial members submitted through the e-referral system could be subject to clinical review.

This policy began on Oct. 5, 2020. Clinical review is a process that our facilities already follow for acute care admissions for our Medicare Advantage members (Medicare Plus Blue℠ and BCN Advantage℠) and Blue Care Network commercial members.

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

Behavioral health authorization requests and clinical reviews will continue according to the current process with the assigned behavioral health management company, working in conjunction with Blue Cross. However, inpatient admission authorization requests processed through New Directions will be subject to full clinical review from the first day of admission and are subject to non-approval.

We’ve let affected facilities know whether their inpatient medical and behavioral health admissions require clinical review.

Why we use clinical reviews
Clinical reviews like this have become necessary as customers look for ways to reduce the amount they spend on medical services and we try to consistently apply utilization management programs across our lines of business.

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

If you’re not already familiar with the e-referral system or how the process works, refer to the Training Tools page on our ereferrals.bcbsm.com website. If you need to sign up for access to the e-referral system, refer to the Sign Up or Change a User page on the website. If you still have questions, contact your provider consultant for more information.