Inpatient medical hospital peer-to-peer review request process changing for Blue Cross and BCN members

Effective Jan. 4, 2021, Blue Cross Blue Shield of Michigan will no longer accept peer-to-peer requests for Medicare Plus Blue℠ members regarding inpatient medical hospital admission denials.

Facilities are encouraged to follow the two-level provider appeal process for Medicare Plus Blue to reevaluate the denial decision on an inpatient admission request. See the “Contracted MI Provider Acute Inpatient Admission Appeals” section in the Medicare Plus Blue℠ PPO Manual.

For our Blue Care Network commercial, BCN Advantage℠ and Blue Cross commercial members, we’re still accepting peer-to-peer review requests. For these members, facilities must submit peer-to-peer review requests within seven days of the date the authorization request was denied.

We’ll update the document titled How to request a peer-to-peer review with a Blue Cross or BCN medical director to reflect the changes in the process for all lines of business. This document can be found on our ereferrals.bcbsm.com website on these webpages:

• BCN Authorization Requirements & Criteria webpage— Look under the Referral and authorization information heading
• Blue Cross Authorization Requirements & Criteria webpage — Located in both the Blue Cross PPO and Medicare Plus Blue PPO sections of the page

Before submitting prior authorization requests for inpatient hospital admissions, Blue Cross and BCN encourage hospitals to provide all clinical documentation needed to validate medical necessity criteria.