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Pre-certification Process Update

February 8, 2012 

Recently, some providers may have experienced challenges communicating with our Care Coordination areas. This may be due to the fact that BCBSIL has shifted from the requirement to pre-certify an inpatient stay with clinical information to a simpler prenotification process. We apologize for any inconvenience and thank you for your patience during this transition.

Please be assured that, despite process changes, you will receive payment as usual for services rendered, according to the member’s benefits and our contractual agreements at the time of service. 

At BCBSIL, we are focusing on discharge planning and case management, in support of moving our members to the next level of care as quickly as possible. This means that hospital providers may see some changes in process flow, particularly with regard to pre-certification. The guidelines below are intended to provide a general outline of the steps involved. 

Notification of Admission

To notify BCBSIL of an admission, you may contact BCBSIL in one of two ways:

  • Electronically, via  iEXCHANGE®,  our automated online tool which supports direct submission and processing of pre-certification for inpatient admissions 24 hours a day, seven days a week; or
  • By telephone, using the pre-certification/prenotification number on the back of the member’s ID card.

You will be provided with a case number.* In most instances, the days you request (up to five days) will be automatically allowed. If additional information is required, a BCBSIL RN will contact you within 24 hours. After 24 hours, you may check the status on iEXCHANGE using the assigned case number. If the patient is discharged prior to the last allowed day, additional action is not warranted. 

*It is important to document the case number for follow-up purposes.

Extensions to Length of Stay (LOS)

You may request an extension on iEXCHANGE by accessing the patient record with the assigned case number. The request for an extension must be entered in iEXCHANGE prior to midnight on the last day that was allowed by BCBSIL. After 24 hours, you can view status of the request in iEXCHANGE. 

A BCBSIL RN will contact you to request clinical information and provide a return phone number. When you contact BCBSIL using the phone number provided, please note that you may have to leave clinical information on a secured voicemail system. You should provide a brief clinical summary of the initial stay, with a detailed description of the current clinical picture requiring the continued stay, along with a comprehensive overview of the discharge plan. Extensions are reviewed and approved based on Milliman Criteria. 

We are strongly discouraging the faxing of clinical reviews since the transmittal does not convey the information required and may delay processing. Additionally, automated faxes from your electronic medical records system do not provide us with the information to provide the best service to our members while also anticipating their future needs.

The introduction of value-based care models, such as Accountable Care Organizations (ACOs), Intensive Medical Home programs and other risk-based reimbursement programs has shown us that our focus should be on targeting overall care management of high-risk populations, as providers are better equipped to manage the day-to-day clinical care of the majority of our members. We are confident that you are appropriately managing your patient’s care. However, we will continue to trend LOS through claims analysis on a regular basis; we will also trend your overall performance relative to national and local benchmarks. 

If you need additional information—especially if you would like to learn more about the benefits of using iEXCHANGE and other electronic options—please contact your assigned Provider Network Consultant. 

The above information is specific to BCBSIL PPO members only. For out-of-area members, please use the Pre-cert/Pre-auth Router (Out-of-area members) located in the Claims and Eligibility/Prior Authorization section of our website at bcbsil.com/provider.  Pre-certification also may be required for outpatient services for some employer groups. No changes have been made to the BCBSIL approval process for maternity cases; the approved LOS for maternity cases stays the same (two or four days), depending on delivery method. 

Please note that the fact that a guideline is available for any given treatment or that a service has been pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. Certain employer groups may require pre-certification for certain services from other vendors. If you have any questions, please call the number on the back of the member's ID card.