Posted April 1, 2021
Blue Cross and Blue Shield of Illinois (BCBSIL) may provide reimbursement for authorized inpatient stays extended beyond medical necessity, also known as Administrative Days (ADs), for some Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members.
ADs are inpatient stay days for members who no longer require acute hospital care, but discharge to a sub-acute or post-acute setting has proven problematic due to the unique circumstances of these members.1
It’s expected that providers will consider any unique circumstances early in each member’s stay and will begin working collaboratively with BCBSIL Utilization Management and Care Management Coordinators on discharge planning as soon as potential barriers are identified. It’s the responsibility of the facility to ensure reasonable efforts are made to engage BCBSIL in discharge planning and to ensure barriers to discharge are documented in advance of the discharge date. If you have a BCCHP or MMAI member that meets the AD description above, a prior authorization request specifically for the AD is required through BCBSIL within one business day from the member’s transition in level of care.
Always check eligibility and benefits through the Availity® Provider Portal or your preferred web vendor prior to rendering care and services to BCBSIL members. This step will confirm membership status, coverage details and prior authorization requirements.
How to request prior authorization for ADs: Prior authorization requests may be made by phone (call 877-860-2837 for BCCHP members, call 877-723-7702 for MMAI members) or by fax to 312-233-4060 (same fax number for BCCHP and MMAI). Prior authorization requests for ADs may not be submitted online at this time.
Prior authorization through BCBSIL is required for all planned inpatient care. The following information should accompany the prior authorization request for admin days:
- Documented discharge plan in place to a lower level of care
- Documented attempts to place the member
- Documented barriers to implementation of the discharge plan which are beyond the control of the provider
Exclusionary Criteria: A member will not qualify for ADs if any of the below points apply. Please review these criteria before submitting an AD prior authorization request.
- The member has met their discharge criteria and barriers to discharge no longer exist.
- The inpatient facility is pursuing a discharge to a level of care or service that BCBSIL has stated is not a covered benefit for the member.
- The facility has not worked with BCBSIL to identify alternative and appropriate placements.
- Long Term Acute Care Hospitals (LTACHs) are not eligible for ADs reimbursement.
- BCBSIL is not responsible for ADs that are the responsibility of the Illinois Department of Children and Family Services (DCFS).
Reimbursement rates are defined by the Illinois Department of Healthcare and Family Services (HFS). Medicaid High Volume Adjustments (MHVA), Medicaid Percentage Adjustment (MPA) or any other add-on payments do not apply to ADs. Information regarding prior authorization, claims and reimbursement may be obtained through the facility’s Provider Networking Coordinator.
For more information, review the IAMHP Administrative Days memo.
1 IAMHP, Administrative Days Reimbursement Implementation, 2019. https://iamhp.net/resources/Documents/AD%20Days%20Implementation%20%20FINAL%201-22-21%20.pdf
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized 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. If you have questions, call the number on the member’s ID card.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.