Prior Authorizations to Transfer Members to Post-Acute Care Resume May 16, 2020

May 15, 2020

As previously mentioned on April 28, the following accommodation ends on Friday, May 15, 2020. Please revert to your processes in place before April 1, 2020. All prior authorizations requirements will apply starting May 16, 2020.

Blue Cross and Blue Shield of Illinois (BCBSIL) is making it easier to transfer our members from acute-care facilities to in-network, medically necessary alternative post-acute facilities until May 15, 2020.

We will no longer require a post-acute care facility to wait for prior authorization to transfer our members from an inpatient hospital to an in-network medically appropriate, post-acute site of care such as long-term acute care hospitals, skilled nursing facilities, rehabilitation facilities and in-patient hospice. The receiving facility must call and inform us of the transfer by the next business day.

This will help promote availability of acute care capacity for COVID-19 patients during this Public Health Emergency. It also allows our members to continue to access medically necessary care. 

If the transfer is for a behavioral health facility, it will require prior authorization.

Which members will benefit?
This applies to the following PPO and Blue Choice PPOSM members:

  • Fully-insured
  • Self-funded group
  • Retail
  • Medicare Advantage
  • Medicaid (subject to approval by local regulators)

It does not apply to HMO or Federal Employee Program® (FEP®) members at this time.

How to Transfer a Member
You can move members who are medically stable for transfer to the safest, most appropriate in-network place of care. You do not need our approval for transfer to any post-acute care facility that is:

  • In-network consistent with the member’s plan (e.g. a PPO member could be transferred to an in-network PPO facility)
  • Medically appropriate for the member and medically necessary
  • Available and accepting transferred members

The receiving facility should notify us the following business day. Once our member is transferred, our standard utilization management processes will apply as described in more detail below.

Standard Utilization Management Process
After the post-acute care facility notifies us, our utilization management care manager will not review the admission for medical necessity. They will work with the post-acute care facility to:

  • Approve the admission without records for seven days
  • Manage the ongoing stay for concurrent review
  • Work with the facility for discharge planning

Post-acute care facilities must notify us of the admission, but they do not have to send records or wait for authorization before admitting our members.

How long is this process in effect?
The utilization management process modification will be in effect through May 15, 2020. We will then determine if it needs to be extended to best serve our members.

Important Reminders

  • State and federal laws and regulatory requirements will supersede these guidelines.
  • We maintain the right to retrospectively review health care services submitted for claims payment for accuracy and appropriateness.
  • This change to member prior authorization requirements is subject to in-network facility access.