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

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 and Federal Employee Program (FEP) members.

While notification of an inpatient admission from the emergency room will no longer be required, providers will be strongly encouraged to continue to notify Blue Cross NC of a member admission to ensure proper coordination of discharge planning and transition of care. If notification is not provided at the time of member admission, inpatient claims will still be subject to review for appropriate level of care. Likewise, medical records will also be required for review.

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.
• In-network providers should continue to notify Blue Cross NC at the time of an emergency room to inpatient admission; however, notification is voluntary.
• Emergency room benefits will be applied to emergency room/observation and emergency room/in-patient (the entire length of stay).
• Blue Cross NC will pend services conducted during an emergency room to inpatient admission episode that requires prior plan authorization (PPA) for a retrospective medical necessity review.
• Additionally, if notice is provided prior to admission, Blue Cross NC will review records to determine if observation is a more appropriate setting and advise the provider. If the provider admits the member, Blue Cross NC will review the claim retrospectively and pay according to their determination.

Blue Cross NC will communicate additional details, guidance documentation and an FAQ for impacted providers prior to January 1, 2022.