MA PAP 306
Provider Administrative Policy
Provider Prior Authorizations
Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts
Blue Cross of Idaho members requiring care in a hospital, skilled nursing facility or other facility will receive care in the setting that provides the most appropriate level of medically necessary care.
Blue Cross of Idaho’s Medical Quality Management (MQM) case managers perform admission and concurrent review by working collaboratively with acute facilities, skilled nursing facilities and other facilities to assess the appropriate setting and the level of care prescribed for confined members.
Planned admissions conducted on an inpatient or outpatient basis must follow Blue Cross of Idaho’s preadmission authorization requirements. If you do not follow these requirements it may affect how we pay the claim. (See MA PAP300 and/or MA PAP301)
For unplanned emergent admissions, follow the procedure listed below.
1. Notify Blue Cross of Idaho's MQM department within one business day of an unplanned admission via notification at bcidaho.com
- Access the Web site at bcidaho.com
- Select Medical Providers and log in
- Select Authorizations/Notifications under Quick Links
- Select Search Request in the authorization system to verify if an authorization is already established.
- If the authorization is not showing in the Search Request screen, select New Request
- Select member and proceed with the Inpatient Notification (Facilities ONLY) to enter member information
- Select Submit when all steps are completed
- Print or electronically capture the abstract that displays the reference ID. Upload any necessary documents with the notification or you may fax the abstract that may be used as the cover sheet when you send required medical records. You may also provide notification via phone or fax. The facility is responsible for providing medical records for use in making an admission determination.
2. Upon notification and receipt of medical records, Blue Cross of Idaho will conduct a clinical review to determine medical necessity and appropriateness utilizing the clinical review tools below. Clinical reviews will not delay a member's access to care.
Medicare Advantage Clinical Review Tools
Summary of Benefits and Evidence of Coverage (Member Benefits)
National Coverage Determinations (CMS Benefits and/or Medical Necessity)
Regional and Local Coverage Determinations (CMS Benefits and/or Medical Necessity)
Blue Cross of Idaho Medical Policies (Medical Necessity)
McKesson Care Enhance Review Manager/InterQual (Medical Necessity)
Nationally recognized clinical guidelines for advanced radiology studies (AIM) Ingenix/Encoder (Place of service based on Medicare OPPS Status Indicators) (OPSI)
3. Blue Cross of Idaho will contact the facility’s designated Utilization Management department via fax, email or phone with an admission determination within two business days of being notified (inpatient, outpatient, observation). If appropriate, we will specify a number of days we authorize and a date for the next review. If the facility discharges the member prior to the next review date, it is the facility’s responsibility to contact Blue Cross of Idaho’s MQM department and provide a discharge date to complete the authorization.
4. It is the responsibility of the facility to provide Blue Cross of Idaho an update on the patient’s continued hospitalization and provide the following information:
- Medical information and any additional information needed to evaluate the continued stay.
- Clinical findings including, but not limited to:
• Patient status
• Level of care
• Patient progress
• Severity of illness
• Intensity of service
5. If the continued stay is determined appropriate Blue Cross of Idaho will notify the facility within one business day of the following:
- The number of days authorized for the continued stay.
- The date the facility is required to provide the next clinical review.
6. If the clinical information does not support continuing the stay:
- A Blue Cross of Idaho case manager will not authorize additional days.
- A Blue Cross of Idaho case manager will request an immediate review of the current clinical information by a medical director or physician designee.
- The Blue Cross of Idaho medical director or physician designee may consult with the attending physician.
- If the medical director or physician designee does not authorize additional days, the Blue Cross of Idaho case manager will initiate the standard procedure for denials and notify the facility of the determination within one business day.
7. If the medical director or physician designee approves the request to extend the length of stay a Blue Cross of Idaho case manager will:
- Notify the facility’s Utilization Management department within one business day.
- Document the authorization and clinical findings.
- Inform the facility of the next clinical review date.
8. The facility is responsible for initiating all concurrent reviews. If a facility does not provide Blue Cross of Idaho’s MQM department with the review and the appropriate information, approval and payment of additional hospital days
may be affected.
9. The facility is responsible for informing Blue Cross of Idaho of any discharges via fax, telephone, census or the eligibility and claims system available at bcidaho.com.
(See MA PAP102) Failure to do so may affect payment of the claim.
|December 2013||Revised||Bullet 1. Process updated.|
|August 2010||Revised||Notification of unplanned admission revised to one day|