Reminder: PPO inpatient admission requests submitted through e-referral may be subject to clinical review

As we notified you in the January Record, inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial members submitted through e-referral may be subject to clinical review, effective January 2020. It’s a process we were already following for Medicare Plus Blue^SM  inpatient acute care admissions and certain other members.

Clinical reviews are necessary to make sure inpatient admissions are medically necessary. These reviews also help Blue Cross verify patient stays are appropriate and billed correctly based on diagnosis and condition.

Throughout 2020, select facilities must submit medical inpatient stays through e-referral. These stays will be subject to full clinical review from the first day of admission and subject to non-approval by clinical professionals, using InterQual guidelines.

Behavioral health authorization requests and clinical reviews will continue to follow the current process with the assigned behavioral health management vendor. However, inpatient admission authorization requests processed through New Directions will be subject to full clinical review from the first day of admission and subject to non-approval.

Facilities that need to submit reviews starting in October will be notified midyear.

If you aren’t familiar with e-referral or how the process works, contact your provider consultant.