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Provider Responsibility for Inpatient Precertification Now Includes BlueCard Members

In order to offer all Blue Plan members nationwide access to the highest level of benefits available within their respective benefit plans, as well as to be consistent with the health care management guidelines of the member’s Home Plan, Blue Cross and Blue Shield of North Carolina (BCBSNC) will be making a policy change effective July 1, 2014, that will require BCBSNC-participating providers, hospitals and facilities to be responsible for the precertification* for non-emergency inpatient admissions and related inpatient procedures/services for BlueCard® members in addition to BCBSNC members.

This change will apply to dates of service on or after July 1, 2014.  If precertification for a non-emergency inpatient stay and related services is not obtained by the hospital, facility or admitting provider in advance when required by the member’s Home Plan, the hospital, facility or provider will be financially responsible for any covered services not paid and the member will be held harmless.

Emergency inpatient admissions do not require immediate precertification; however, if the member’s Home Plan requires precertification for non-emergency inpatient admissions and services, certification for the inpatient stay must be obtained within 24 hours after the emergency admission or by the end of the next working day, if on a weekend or holiday (not to exceed 72 hours).  

Many of our network providers and hospitals already handle the inpatient admission certification process with other Blue Plans on behalf of their BlueCard eligible patients, even thought it was not previously required for them to do so, as it was ultimately the member’s responsibility.

Obtaining precertification for inpatient admissions and related services allows BCBSNC (or another Blue Plan where the patient has coverage) the opportunity to review that the admission and the affiliated services meet a member’s Home Plan’s requirements for medically necessity, as well as  appropriateness of care, health care setting, level of care, and anticipated effectiveness.  This information also helps BCBSNC and other Blue Plans assess whether the proposed care may be a covered benefit for the member and advise the provider and/or facility accordingly.     

BCBSNC will be updating the Blue BookSM, which is our online provider e-manual, to include this policy change. 

Please contact your BCBSNC Strategic Provider Relationships consultant with any questions you may have regarding this upcoming policy change.    

*Precertification (also referred to as prior review, prior plan approval, prior authorization, or prospective review)  

Related FAQs:

If a BlueCard eligible member’s coverage plan requires precertification for inpatient services, which services will be the provider’s financial responsibility if precertification is not obtained on the patient’s behalf? 

All inpatient admissions to hospitals and facilities will require precertification from a member’s Home Plan, beginning with admission dates on and after July 1, 2014, if the member’s benefit plan requires inpatient precertification.  Any additional inpatient days that are not certified in advance may become the financial responsibility of the admitting hospital, facility or provider, if not precertified.

Authorization or certification for emergency admissions must be obtained within 24 hours after the emergency admission or by the end of the next working day (not exceeding 72 hours,) if on a weekend or holiday.   

Are outpatient services for BlueCard members included in this new requirement?

No, only inpatient services billed on a UB-04 claim form are included.  Outpatient services billed on UB-04 claim forms and professional services billed on HCFA-1500 claim forms are excluded.   

Are BlueCard Worldwide/International members included?

No, BlueCard Worldwide/International members are excluded.  This new requirement only applies to inpatient admissions and related services for BlueCard members within the U.S.

If a member elects to proceed with an inpatient admission that the Home Plan has denied certification, can the member be billed?  

Some BCBS Plans may allow their members to be held financially responsible when certification is denied and a member elects services and agrees to be financially responsible.  In the event that an inpatient admission or inpatient service has been denied certification by a member’s Home Plan, the member’s potential financial responsibility should be discussed in advance with the member’s Home Plan before deciding whether or not to proceed with impatient services that have been denied certification, even if the member has agreed to pay. 

What are the timeframes for requesting inpatient certification from a member’s Home Plan?     

Precertification requests are to be made in advance of a scheduled inpatient admission.  Providers must notify the member’s Home Plan within 48 hours when a change to the original pre-service review occurs, and within 72 hours for emergency and/or urgent inpatient admissions.  Providers will be responsible for keeping the member’s Home Plan informed of changes to a member’s condition.

What happens if inpatient certification is required for a BlueCard member but is not obtained?

Inpatient providers and facilities that fail to obtain precertification from a member’s Home Plan will be financially responsible for any covered services not paid and the member will be held harmless.

How can I find out if a member’s inpatient stay or services requires certification from the member’s Home Plan?  

Providers can access a member’s Home Plan’s Web site to inquire about and make certification requests.  Requests for pre-service review for BlueCard members (not BCBSNC members) can be routed to the member’s Home Plan via an electronic provider access routing system accessed via Blue eSM.  BCBSNC providers can connect through Blue e to BlueCard members’ Home Plans to request authorizations for inpatient stays, as well as approvals for inpatient procedures and services that require advanced certification.