Blue Cross and Blue Shield (Blue Cross NC) continues to review all guidelines and information related to the federal government No Surprises Act. We are providing updates to the previously published notification from November 2021.
Effective October 1, 2022, Blue Cross NC will request that notification of a member’s emergency inpatient admission is made by the facility within 2 business days of admission. If this voluntary notification includes an authorization request, a medical necessity review of the medical record information submitted will be conducted, and if MCG guidelines for inpatient admission have been shown to be met, a certification will be authorized. If there is insufficient information showing that, MCG guidelines have not been met, or inpatient admission is not medically necessary, a Blue Cross NC Medical Director (MD) will issue a denial determination. As a courtesy to our providers, we will accept additional written clinical information and rationales for reconsideration that show how MCG Care guidelines are met and that inpatient admission is medically necessary.
Standard appeal rights are available without requirement for use of the provider reconsideration process.
Should the provider still file an inpatient claim after a denial has been issued, the claim will be denied citing the initial medical necessity review.
In the event a facility does not provide us with voluntary notification of a member’s admission, and files an emergency inpatient claim, then a post-service medical necessity review will be completed and either an approval or MD denial will be issued.
Please be advised that any inpatient admission that is not the result of an emergency room encounter or emergent transfer from another hospital is NOT in-scope for Surprise Billing claim processing procedures. This would include but is not limited to direct admissions from home, provider office or urgent care, maternity or neonatal admissions, or admissions that are a result of a complication from a planned outpatient procedure. For these non-emergency services, prior authorization is required.
- All providers are requested to notify Blue Cross NC at the time of an emergency room to inpatient admission; however, notification is voluntary.
- Inpatient authorization request determinations will be made within 72 hours and notification will be provided via fax or Blue e Care Affiliate electronic portal.
- Courtesy reconsiderations are available only for denials issued when voluntary notification has been provided. [Peer-to-peer discussion with a Blue Cross NC MD are not required nor are they necessary in most cases as written documentation may be provided to show how MCG guidelines have been met and that the admission is medically necessary. Peer discussion will only be conducted with the attending or treating physician who is a member of the medical staff of the hospital; non-treating utilization review physicians who are employed by a third party are not eligible for peer discussions].
- All providers should ensure records are available and/or submitted in a timely manner to avoid denials. In the event a denial is issued for insufficient medical record documentation, please submit all the required information in writing for the courtesy reconsideration.
- Any emergency to inpatient claims filed that did not receive a determination for level of care will pend for medical necessity review.
- Determinations will be made within 30 days of receipt of plan notification; claim approvals will be communicated via EOB/EOP and any medical necessity denial letters will be mailed.
- No reconsiderations will be allowed after this type of post-service review; standard appeal rights are available.
- While coverage for emergency inpatient services will not be denied for not obtaining precertification, any services on the Blue Cross NC Prior Authorization list will still require medical necessity review, even when conducted during an emergency admission.