Additional update: We’re aligning local rules for acute inpatient medical admissions

For certain conditions, authorization requests for acute medical admissions should be submitted only after the member has spent two days in the hospital. Once two days has elapsed, the facility can submit the request to authorize an inpatient admission on the third day. 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 a critical care setting, you can submit the request prior to completion of the two-day 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 date for this change

This update to local rules will go into for all members on or after March 1, 2022.

This applies to members with the following conditions:

How determinations will be made

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.

After receiving the request from the hospital 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 two days of hospital care.
• Ensure appropriate reimbursement (inpatient versus observation level of 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 provider manual for information on how to submit an appeal.