We’re aligning local rules for acute inpatient medical admissions for Blue Cross commercial plans and requesting your input

This article focuses on the alignment of local rules for acute inpatient medical admissions for Blue Cross Blue Shield of Michigan commercial plans. There’s a separate article in this issue on aligning local rules for Blue Care Network commercial, Medicare Plus Blue℠ and BCN Advantage℠ plans.

Blue Cross Blue Shield of Michigan is working to align local rules across all plans for acute inpatient medical admissions. We’re implementing a local rule for specific conditions that could appropriately be managed in an observation setting for at least 48 hours.

The following conditions should be submitted for clinical review once the 48-hour observation stay is met:

For patients with a Blue Cross commercial plan, the program will begin with admissions on or after March 1, 2022.

This program will decrease provider burden by decreasing receipt of multiple communications and the need to submit multiple requests for clinical documentation. It will also have an impact on authorizations denied for lack of clinical information as all clinical documentation to support the admission would be received after 48 hours of observation care.

Observation requirement

For patients diagnosed with conditions listed in the local rule, the patient must be observed for 48 hours before a facility can request prior authorization for an inpatient acute care admission. For admissions where patient is receiving intensive care services requiring an ICU setting, authorizations will be accepted prior to the 48-hour observation period.

Once the 48-hour observation stay requirement is met or patient is receiving intensive care services, a medical necessity review will be conducted based on the supporting clinical documentation submitted by the provider. InterQual criteria will be applied based on the patient’s condition when the patient transitions from 48-hour observation stay to an inpatient admission or is receiving intensive care services.

• If InterQual criteria is met, the prior authorization request will be approved.
• If InterQual criteria isn’t met, the prior authorization request will be sent to the plan medical director for review.
• If the patient hasn’t met the 48-hour observation requirement, the prior authorization request will be sent to the plan medical director for review.

Applicable peer-to-peer review requests and appeals will remain available for those cases in which a facility disputes the severity of illness and intensity of services provided were higher than an observation.

Requesting input

We’re requesting your input on the alignment of local rules for inpatient acute care admissions detailed in this article. Please submit your input to Liz Bowman at ebowman@bcbsm.com by Oct. 31, 2021.

Per the Participating Hospital Agreement, effective July 1, 2021, the Contract Administration Process >was revised to allow for non-binding input from all participating hospitals. After input is received, Blue Cross Blue Shield of Michigan has 30 calendar days to respond to facility input.