Inpatient admission requests submitted through e-referral for commercial members may be subject to clinical review

Starting Oct. 5, 2020, inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial members submitted through e-referral could be subject to clinical review. It’s a process that our facilities already follow for Medicare Plus Blue℠ inpatient acute care admissions and some other members.

As part of our inpatient review program, select facilities must submit medical inpatient stays through e-referral. 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, a company that provides behavioral health services for most Blue Cross members, will be subject to full clinical review from the first day of admission and subject to non-approval.

We’ve notified the affected facilities that their inpatient medical and behavioral health admissions require this new clinical review process.

Why we use clinical reviews
Clinical reviews are necessary to help customers determine ways to reduce the amount they spend on medical services and help us consistently apply utilization management programs. These reviews also help ensure that the patient stays are appropriate and billed correctly based on the patient’s diagnosis and condition.

Blue Care Network and our Medicare Advantage plans already have full inpatient review programs at Michigan hospitals.

If you’re not familiar with e-referral, please see the table below for available online training dates (each training is one hour):