Update: Behavioral Health Medicare Advantage Concurrent Review

Update April 18, 2025: As referenced in the original communication posted on March 21, 2025, Medicare Advantage Behavioral Health concurrent review for additional inpatient days was scheduled to start May 1, 2025. The effective date is now June 1, 2025.

Effective May 1, 2025, requests for Medicare Advantage Behavioral Health concurrent review for additional inpatient days will be reviewed utilizing the Centers for Medicare & Medicaid Services (CMS) Medicare Coverage Database.

Moreover, an additional source that Behavioral Health Episodic Case Managers will use for medical necessity beginning May 1 is the Milliman Care Guidelines.

The determination for the additional inpatient days will be made based on the Medicare necessity criteria, which can be found on the CMS website.

For questions regarding this change, email BehavioralHealth@bcbsnc.com.