Physicians/Specialists
Facilities/Hospitals
Ancillary
Publication Date: 
2019-11-25

It's becoming more important to assist members and providers with transition-of-care planning. Therefore, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will begin requiring a more proactive discharge-planning strategy, effective January 1, 2020.

As a valued provider who is also committed to making sure our members receive quality care, we ask for your partnership as we take a more proactive approach to discharge planning.

Key Points

  • Effective January 1, 2020, Blue Cross NC's Utilization Management (UM) staff will use MCG's industry-leading, evidence-based care guidelines to understand, set, and meet our members' recovery-care milestones.
  • MCG provides benchmark data and statistical information about services for members with certain diagnoses and conditions.
    • This data allows organizations to compare utilization performances against regional and national benchmarks for multiple indicators.
    • Data for each region is standardized to reflect the average demographics (age and gender) of the national population.
  • MCG also provides Blue Cross NC with Optimal Recovery Course paths, sharing situations in which patients' hospital stays could potentially extend beyond the goal length, along with expected evaluations and therapeutic options to treat conditions and symptoms.
  • This enhancement applies to members in acute hospital settings from all lines of business, including:
    • Commercial
    • State Health Plan
    • Federal Employee Program
    • Medicare Advantage
  • Adopting these guidelines will help us:
    • More effectively manage our members' transition-of-care phases
    • Develop strategies to reduce patients' lengths of care
  • For facilities that provide us with EMR access, we will continue collecting records ourselves, and will communicate regularly with your UM team to request updates and discuss goals and barriers.
  • For facilities that do not offer EMR access, Blue Cross NC UM staff will likely make more frequent requests for updated clinical records based on MCG's length-of-stay goals. We appreciate your prompt response via Provider Link, fax, or Blue e.