Timely Post-stabilization Notification of Inpatient Admissions Requirement for Select Government Programs

Posted December 21, 2016

Please refer to the information below for important pre-service updates and reminders for the following government programs: Blue Cross Medicare AdvantageSM and Blue Cross Community OptionsSM. Specifically, this information applies to Blue Cross Medicare Advantage (PPO)SM (MA PPO), Blue Cross Community MMAI (Medicare-Medicaid Plan)SM, Blue Cross Community Integrated Care Plan (ICP)SM and Blue Cross Community Family Health PlanSM (FHP).

Checking eligibility and benefits for every member before rendering care and services is always an important first step. When you check eligibility and benefits for a particular MA PPO, MMAI, ICP or FHP member, you will be alerted if benefit preauthorization is required for certain services, drugs, devices and equipment.

As a reminder, submitting a benefit preauthorization request is required for all inpatient admissions, as well as to request additional days beyond the approved length of stay, if necessary. Effective April 1, 2017, Blue Cross and Blue Shield of Illinois (BCBSIL) will require notification of inpatient admission for post-stabilization care within one business day following the stabilization of an emergency medical condition.

Timely post-stabilization notification of inpatient admission helps BCBSIL evaluate the setting of care and other criteria for coverage purposes. It aids in early identification of members who may benefit from specialty programs available from BCBSIL, such as Case Management, Care Coordination and Early Intervention (CCEI), or Longitudinal Care Management (LCM). Notification also allows BCBSIL to assist the member with discharge planning. 

Failure to timely notify BCBSIL and obtain benefit preauthorization for further post-stabilization care services may result in denial of the claim(s) for such post-stabilization care serviceswhich cannot be billed to the member, pursuant to your provider agreement with BCBSIL. If a claim that includes emergency care services is denied, the provider may rebill the claim for the emergency services (including stabilization services), as well as post-stabilization care services for which BCBSIL may be financially responsible, for possible re-adjudication by BCBSIL.

Inpatient admission, notification and extension requests may be submitted electronically through iExchange®, our electronic benefit preauthorization tool. If you do not have online access, you may call the Customer Service number on the member’s ID card. For additional information, refer to the Standards and Requirements/Provider Manual section. If you have questions, contact your assigned Provider Network Consultant.

Please note that the fact that a service has been preauthorized/pre-certified/pre-notified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.