Prior Authorization Changes for Inpatient Admissions Following Emergency Department Visit - Effective January 1, 2022

As previously communicated in early November, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will no longer require prior authorization for inpatient admission from the emergency room, effective January 1, 2022, for Commercial members. If notification is not provided at the time of the member’s admission, any submission of inpatient emergent claims will still be subject to review of medical records for appropriate level of care.  

To better assist providers and members during and after an emergent admission, we do strongly encourage you to continue notifying Blue Cross NC at the time of admission to ensure coordination of discharge planning and transition of care. For notification made at time of admission, Blue Cross NC clinical staff will review available records, and communicate a recommendation for appropriate level of care (inpatient or observation).  Please be advised, this is considered a voluntary review and any recommendations made for observation level of care are not considered to be a denial or non-certification.  

Key Points  

• Blue Cross NC is removing requirements that notification must be made within two business days of an inpatient admission from the emergency room; you may submit a voluntary notification of admission at any time while the member is still inpatient.    
• If Blue Cross NC recommends observation level of care as part of a voluntary notification, Provider Courtesy Reviews, Peer to Peers and Appeal rights will not be available, as this is not considered a denial.  
• Any claims filed contrary to the recommended level of care will be reviewed anew for medical necessity with all available medical records at the time of the claim filing or when a voluntary review was not submitted; please be prepared to submit medical records with your claim submission.  (Blue Cross NC Utilization Management staff will continue to retrieve medical records when we have access to your Electronic Health Record system.)  
• Emergency room benefits will be applied to emergency room/observation and emergency room/inpatient (the entire length of stay).  
• All prior authorization requirements for procedures that occur as part of an emergent inpatient admission still apply. 

NOTE: There will be no changes for FEP membership at this time; pre-certification and benefits for emergency and inpatient services will remain the same.