Starting July 1, 2023, we will require notification within 48 hours of all member admissions (24 hours for Medicare Advantage members). However, we won’t always require prior authorization. These points clarify our updated notification and authorization requirements for inpatient admissions:

POST-ADMIT NOTIFICATION: Applies to all inpatient admissions
We require notification for all inpatient admissions (even if previously authorized) within 48 hours of admission (for Medicare Advantage plan members, within 24 hours or the next business day). Your notification triggers our concurrent review process.

PRIOR AUTHORIZATION: Applies to certain inpatient services
In addition to notification, we require prior authorization for non-emergency admissions related to procedure codes on our prior auth code lists.
Also:

Most groups with customized prior authorization lists require prior auth for all non-emergency admissions. This applies to members with ID prefixes S3Z, SYD, SWB, SNK, and TYW.

The Federal Employee Program^® (FEP^®) requires precertification or prior approval for all inpatient admissions except emergencies. Emergency admissions require notification and authorization for a continued stay within two business days of the admission. Even if the member has been discharged, notification is still required.

POST-ACUTE CARE FACILITY ADMISSION: Always requires prior authorization
We require prior authorization for all admissions to post-acute care facilities, including:

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Skilled nursing facilities (SNFs)

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Inpatient rehabilitation facilities (IRFs)

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Extended active rehabilitation facilities (EARs)

•

Long-term acute care hospitals (LTACHs)

•

Behavioral health residential treatment centers (RTCs)

Transfers to different levels of care

When a member is transferred from observation to inpatient care, notification is required. Transfers from acute to post-acute care require prior authorization. Other transfers between different levels of inpatient care within the same facility do not require notification or prior authorization. However, transfers between acute care facilities for the same or a lower level of care and do require prior authorization.

Questions?
If you have questions about these updates, please call us at 602-864-4321 or contact your provider liaison.

In This Issue

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May news: Executive summary

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Inpatient care: Notification and authorization updates

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Billing clarification: Inpatient and observation visits

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Include the rendering provider for "clean" claims

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Behavioral health inpatient discharge and follow-up

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BCBSAZ fee schedule updates

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