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

July 31, 2014


As previously communicated, effective July 1, 2014, participating providers became responsible for obtaining preapproval for inpatient facility services for out-of-area members. Dates of admission on or after July 1, 2014, aresubject to this requirement, and the out-of-area member is held harmless.

While most providers currently obtain preapproval for inpatient facility services, this new requirement moved financial responsibility for lack of preapproval from the member to the provider. Failure to obtain preapproval for inpatient facilityservices for out-of-area members will result in a denied claim. To avoid claim denials, it is important to preapprove theinpatient stay and check that additional days are authorized before an out-of-area member is discharged.

Inpatient stay extensions for DRG/case rate facilities

In diagnosis related group (DRG)/case rate situations, when the length of an inpatient stay extends beyond thepreapproved length of stay, any additional days should be approved by the last day of the originally approved days.For example, if five days are approved by the Home Plan and the patient has not been discharged by the fifth day,the provider should contact the Home Plan and ask to have the authorization updated. Please ensure that you seekapproval of additional days to avoid payment issues.

Denied days within an approved inpatient stay for non-DRG/case rate facilities

In non-DRG/case rate situations, 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.

Getting preapproval for out-of-area members

Providers can obtain preapproval of inpatient facility services for an out-of-area member through one of the following:

  • Telephone. Providers can call the BlueCard Eligibility® line at 1-800-676-BLUE and ask to be transferred to the utilization review area.
  • NaviNet® web portal. Starting in mid-August, IBC providers will be able to submit electronic reapproval requests for out-of-area members through NaviNet. Please refer to the article titled Pre-service review for out-of-area members will be made available through NaviNet.

Please note that providers must notify the member's Home Plan within 48 hours when a change or modification to the original pre-service review occurs. Providers must also notify the member's Home Plan within 72 hours for emergency/urgent pre-service review.

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