February 1, 2017
Beginning Jan. 1, 2017, Blue Cross and Blue Shield of Nebraska (BCBSNE) changed its precertification requirements. For all acute (non-emergency) inpatient and observation admissions to hospitals or facilities, BCBSNE will require precertification on or before the first day of admission.
This change applies to any of your patients that are covered by BCBSNE while living or traveling in Washington/Alaska and accessing care through the BlueCard program. Member ID cards will indicate the BCBSNE name and will have the BlueCard symbol.
What is the requirement?
Precertification enables BCBSNE to determine if services are appropriate under terms of the patient's health plan, and coordinate discharge planning and case management services with the patient's providers.
Clinical information must be submitted in order to determine medical necessity and level of care (inpatient stay or observation ). InterQual® criteria (decision management criteria) will be used to review the precertification requests.
The requirement to precertify admissions on day one is the responsibility of hospital or facility staff and not the individual rendering provider.
Guidelines for submitting precertification:
- Planned admissions can be certified prior to admission date.
- Precertification notification for unplanned admissions should occur on the first business day following admission.
This requirement doesn't apply to:
- Customers with Medicare Supplement coverage
- Customers for whom BCBSNE is secondary to another payer
- Hospital stays for labor and delivery (48- or 96-hour admissions)
What are the requirements for the precertification review?
Precertification is required for coverage. If precertification isn't completed for all acute inpatient and observation admissions, the claims for these services may be denied and the patient may be responsible for full payment.
Services won't be covered if medical necessity criteria aren't met. If a precertification request is submitted and BCBSNE determines that criteria aren't met, benefits won't be available. If the Nebraska customer chooses to receive the services despite the determination (and provides written authorization), services become member liability.
Submission of the precertification review. Hospitals and facilities will log in to Navinet at navinet.navimedix.com/sign-in to access Clear CoverageTM, a user-friendly, web-based precertification tool, which can provide an automatic approval if criteria are met. Clear Coverage will be available on Jan. 3, 2017.
BCBSNE's precertification review program is designed to ensure the necessity and appropriateness of procedures and services for its customers. View this Frequently Asked Questions document for more information.
If you have any questions about this article, call Physician and Provider Relations at 877-342-5258, option 4.