This information applies to Medicaid members.
Blue Cross and Blue Shield of Illinois may provide reimbursement for authorized inpatient stays extended beyond medical necessity, also known as administrative days, for some members with Blue Cross Community Health PlansSM and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM for dates of service on or after July 1, 2019.
Admin days are inpatient stay days for members who no longer require acute hospital care but are in the process of being discharged to a sub-acute or post-acute setting.
Work with us to secure administrative days
It’s expected that providers will consider any unique circumstances early in each member’s stay and will begin working collaboratively with our 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.
Request authorization by phone or fax
Prior authorization through BCBSIL is required for all planned inpatient care. If you have a BCCHP or MMAI member that meets the administrative days description above, a prior authorization request specifically for the administrative days is required through BCBSIL within one business day from the member's transition in level of care.
Prior authorization requests for administrative days may not be submitted online at this time. Call or fax us to request authorization.
- Call 877-860-2837 for BCCHP
- Call 877-723-7702 for MMAI
- Fax 312-233-4060 for either BCCHP or MMAI
Include the following with the prior authorization request:
- Documented discharge plan to a lower level of care
- Documented attempts to place the member
- Documented barriers to implementation of the discharge plan which are beyond the provider’s control
Exclusionary criteria
A member will not qualify for administrative days if any of the below points apply. Please review these criteria before submitting an authorization request for administrative days.
- 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 are not eligible for administrative days reimbursement.
- BCBSIL is not responsible for administrative days that are the responsibility of the Illinois Department of Children and Family Services (DCFS).
Reimbursement rates
Reimbursement rates are defined by the Illinois Department of Healthcare and Family Services. Medicaid high-volume adjustments, Medicaid percentage adjustment or any other add-on payments do not apply to administrative days. Information regarding prior authorization, claims and reimbursement may be obtained through the facility’s Provider Network Coordinator.
Prior to rendering care
Always check eligibility and benefits through Availity® Essentials or your preferred vendor prior to rendering care and services to our members. This step will confirm membership status, coverage details and prior authorization requirements.