December 2021
Update: We’re aligning local rules for acute inpatient medical admissions
What you need to know
We’ve updated the article on this topic that ran in previous issues of The Record and BCN Provider News. Key changes:
- We’ve clarified that authorization requests for inpatient admissions for certain acute medical conditions should be submitted only after the member has spent 48 hours in the hospital.
- We’ve revised the effective date for this change for BCN commercial members from Jan. 3, 2022, to Feb. 1, 2022.
You’ll want to use the following revised article as your reference on this topic.
For certain conditions, authorization requests for acute medical admissions should be submitted only after the member has spent 48 hours in the hospital. Once the 48 hours has elapsed, the facility can submit the request to authorize an inpatient admission. You must provide clinical documentation that demonstrates that the InterQual® criteria have been met at the time you submit the request.
Exception: When a member is receiving intensive care services that require an ICU setting, you can submit the request prior to completion of the 48-hour period, along with all clinical documentation supporting the critical level of care.
We’re aligning our local rules for all lines of business to reflect this change.
Effective dates for this change
This update to local rules will go into effect as follows:
- For Medicare Plus Blue℠ and BCN Advantage℠ members: This change is effective for members admitted on or after Jan. 3, 2022.
- For Blue Care Network commercial members: This change is effective for members admitted on or after Feb. 1, 2022.
- For Blue Cross Blue Shield of Michigan commercial: This change is effective for members admitted on or after March 1, 2022.
Conditions this applies to
This applies to members with the following conditions:
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- Deep vein thrombosis
- Diabetic ketoacidosis
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- Nausea / vomiting
- Nephrolithiasis
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- Skin and soft tissue infection
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- Intractable low back pain
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- Transient ischemic attack
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How determinations will be made
Once the request has been received, Blue Cross and BCN will conduct a medical necessity review based on the clinical documentation you submitted. InterQual criteria will be applied based on the member’s condition at the time the clinical documentation is received:
- If InterQual criteria are met, the authorization request will be approved.
- If InterQual criteria aren’t met, the authorization request will be sent to the plan medical director for review.
- If the member hasn’t been in the hospital for 48 hours and isn’t in the ICU, Blue Cross and BCN will request that the facility wait until the member has been in the hospital for 48 hours to send additional information about the member’s condition. We’ll make the request through the Case Communication field in the e-referral system or by calling the facility, or both.
On the third day, Blue Cross and BCN will do the following:
- If the facility sent additional clinical information and it meets criteria, we’ll approve the request.
- If the facility hasn’t sent additional clinical information or has sent additional clinical information but it doesn’t meet criteria, we’ll refer the request to the medical director for review.
For requests that are nonapproved, Blue Cross and BCN will reimburse as observation. The hospital will need to submit a claim for observation reimbursement.
Reason for change
We expect that this change will:
- Reduce the number of communications that typically accompany these types of authorization requests.
- Decrease denials for lack of clinical information, because all clinical documentation in support of the admission would be received after 48 hours of hospital care.
Additional information
For most members, facilities can request peer-to-peer reviews, if desired. Refer to the document How to request a peer-to-peer review with a Blue Cross or BCN medical director.
In addition, facilities can appeal denial decisions as usual. Refer to the pertinent provider manual for information about how to submit an appeal. |