January 25, 2022 (Updated February 28, 2022)
The information below was posted originally on Jan. 5, 2022; it was updated Jan. 25, 2022, to reflect a new end-date for the interfacility transfer prior authorization waiver. We’re reposting this notice as a reminder and to confirm that the end-date for this utilization management process modification is Feb. 28, 2022.
Effective immediately, 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 Feb. 28, 2022.
Through Feb. 28, 2022, we will not require a post-acute care facility to wait for prior authorization to transfer our members from an inpatient hospital to an in-network medically necessary, 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 change will help promote increased 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.
Please note that if the transfer is for a behavioral health facility, it will require prior authorization.
Which members will benefit?
This applies to the following members:
- Self-funded group
- Medicare Advantage
- Medicaid (subject to approval by local regulators)
It does not apply to HMO because BCBSIL does not manage the prior authorization process. It also does not apply to Federal Employee Program® (FEP®) members at this time.
How to Transfer a Member
You may 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 necessary for the member, which includes a clinically appropriate site of care
- 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 consistent with the member's benefits and as described in more detail below.
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:
- Authorize the admission without medical records for a two-day length of stay
- Manage the ongoing stay after the initial two-day period, including conducting medical necessity reviews on a concurrent basis
- Work with the facility for discharge planning, when appropriate
Post-acute care facilities must notify us of the admission, but they do not have to send records or wait for prior authorization before admitting our members.
How long is this process in effect?
The utilization management process modification will be in effect through Feb. 28, 2022.
- State and federal laws, rules, regulations and guidelines may supersede these guidelines.
- We maintain the right to retrospectively review health care services submitted for claims payment for accuracy