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
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®
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.