Provider financial responsibility for preapproval of inpatient facility services for out-of-area members

May 1, 2014

Effective July 1, 2014, participating providers will be responsible for obtaining preapproval for inpatient facility services for out-of-area members. Dates of admission on or after July 1, 2014, will be subject to this requirement, and the out-of-area member will be held harmless. While most providers currently obtain preapproval for inpatient facility services, this new requirement will move financial responsibility for lack of preapproval from the member to the provider. Failure to obtain preapproval for inpatient facility services for out-of-area members will result in a denied claim. To avoid claim denials, it is important to preapprove the inpatient stay and check that additional days are authorized before an out-of-area member is discharged.

Denied days within an approved inpatient stay

If there are denied days within an approved inpatient stay, the provider will be financially liable for the denied days and the member will be held harmless. In diagnosis related group (DRG)/case rate situations, when the length of an inpatient stay extends beyond the preapproved length of stay, any additional days must be approved by the last day of the originally approved days.

Getting preapproval for out-of-area members

To get preapproval of inpatient facility services for an out-of-area member, providers should call the BlueCard Eligibility® line at 1-800-676-BLUE and ask to be transferred to the utilization review area. Note: Starting in mid-August, IBC providers will be able to submit electronic preapproval requests for out-of-area members using the NaviNet® web portal. We will publish more information about this new capability in future editions of Partners in Health UpdateSM.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.