When you make an authorization request for an emergency inpatient admission on or after December 1, 2015, but you do not submit the supporting clinical information at the time of the request to Blue Cross and Blue Shield of North Carolina (Blue Cross NC), we will request the required clinical information within 24 hours of receipt of your request. This includes weekends and holidays. You will be provided with 48 hours to submit the supporting clinical information to us for review and determination.
If all clinical information needed to support the emergency inpatient admission authorization request is received at the time of the initial request, we will notify you of our decision within 72 hours of receipt of your request.
Once an admission is approved, Blue Cross NC may follow up with you regarding the patient’s discharge planning and length-of-stay (concurrent review) needs. Concurrent review decisions also fall under the urgent timeliness standards.
Why Is Blue Cross NC Making This Change?
We recently received clarification from The National Committee for Quality Assurance (NCQA) that our decision and notification timelines for all emergency admission authorization requests should be based on urgent timeliness standards.
This process change, which is effective December 1, 2015, only impacts Blue Cross NC’s commercial and State Health Plan plans.
Tips to Ensure a Timely Response
While we hope you are pleased that our response to you will be quicker, we also recognize the challenges in getting this information to us in a shorter time frame or outside of your regular business hours.
Here are some tips that will help us work together to successfully process these requests and avoid unnecessary adverse determinations:
- Please provide all necessary supporting clinical information at the time of the initial request. Missing or incomplete supporting clinical information is the main reason for delays in processing your requests and can result in an adverse benefit determination.
- If Blue Cross NC notifies you that supporting clinical information is needed, please submit the clinical information to us within the 48-hour time frame provided. Clinical information can be submitted to us via phone, fax, or ProviderLink (see contact information below).
- When notified that updated clinical information is needed for length-of-stay (concurrent review) needs, please respond to us within the 48-hour time frame. Updated clinical information can be submitted to us via phone, fax, or ProviderLink.
|Contact Information||Phone Number||Fax Number|
|State Health Plan||1-800-672-7897||1-866-225-5258|
While providers can request a Provider Courtesy Review if an adverse determination is made, this process can be time-consuming for both parties. We strive to make the appropriate determination the first time; therefore, submitting complete and accurate information at the time of your request is critical.
Blue Cross NC’s compliance staff will be monitoring this new process on a daily basis in order to assess compliance related to these new timeliness standards. It is our goal to be 100 percent compliant and to consistently strive to eliminate any barriers to meeting these timeliness goals.