Update: Additional guidance on change to inpatient status determination for elective procedures effective February 1, 2026

On December 18, 2025, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) issued a provider notice with additional guidance on a change to how inpatient status is approved for elective procedures for Medicare Advantage (MA) and Dual Eligible Special Needs Plan (D-SNP) products effective February 1, 2026. Since that time, we have received questions about this change from our provider partners. To support clarity and consistent understanding as you care for our members, we are providing the following additional information:

• To support our provider partners and address questions raised during implementation planning, Blue Cross NC changed the effective date from February 1, 2026, to June 1, 2026. This extension provided additional time for communication, education, and operational preparedness.

• Blue Cross NC Medicare Advantage plans, including D SNP, make clinical determinations for inpatient admissions based on the admitting physician’s reasonable expectation at the time of admission, consistent with 42 CFR §412.3(d). Organization determinations are issued within the timeframes required by 42 CFR §422.568.

• For elective procedures not included on the CMS Inpatient Only List, the Plan reviews the requested procedure for medical necessity. Providers may also submit a preservice request for inpatient level of care when they believe the member's clinical condition warrants inpatient admission. Approval of the procedure does not automatically indicate that an inpatient stay is medically necessary.

• For outpatient elective procedures, an inpatient stay may not be required. Inpatient admission may be warranted if:

  • At the time of the request, the member's individual clinical condition, comorbidities, or other complex medical factors, as documented in the clinical record, requires inpatient level of care.
  • During or after the procedure, the member's individual clinical condition changes and/or other complex medical factors exist, and the expectation of the admitting physician at the time of admission, as documented in the clinical record, requires inpatient level of care.

These communications are intended to promote clarity and transparency, ensure alignment with CMS and Medicare Advantage requirements, and support appropriate member cost sharing based on the hospital level of care.

We appreciate your continued partnership in caring for our members and your efforts to apply this guidance consistently. For additional questions or information, contact your Provider Network representative.