Provider Administrative Policy
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 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 PAP241).
For unplanned emergent admissions, please follow the procedure listed below.
1. Notify Blue Cross of Idaho’s MQM department within two business days of an unplanned admission via notification at bcidaho.com
- Access the Web site at bcidaho.com
- Select Providers and log in
- Select Eligibility & Claims
- Select Inpatient to verify if an authorization is already established
- If the authorization is not showing in the Status screen, select Authorization Submission
- Select Inpatient Notification (Facilities ONLY) to enter patient information
- Select Submit when completed
- Print the confirmation that displays the reference ID. This will be the cover sheet for your fax when you send required medical records. You will also receive an email with the same reference ID indicating Blue Cross received the authorization request.
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.
Clinical Review Tools
|Member Contract (Member Benefits)|
|FEP Brochure and Manual (Member Benefits)|
| Blue Cross of Idaho Medical Policies
(Investigational versus Medical Necessity)
McKesson Care Enhance Review Manager/InterQual
|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 one business day 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 PAP100). Failure to do so may affect payment of the claim.
Please refer to PAP279 Clinical Criteria.
|October 2013||Revised||Added link to PAP279|
|July 2013||Revised||Bullet #3 notification to facility from within two business days to one business day|