Providers financially responsible for preapproval of inpatient facility services for out-of-area members

January 5, 2018

Participating providers are financially responsible for obtaining preapproval for inpatient facility services for out-of-area members, and out-of-area members are held harmless for these services.

If providers fail to obtain preapproval for inpatient facility services for out-of-area members or delay the authorization process, then the claim will be denied and the provider will be financially responsible for the lack of preapproval. To avoid claim denials, it is important to preapprove the inpatient stay within the time frames listed below and check that additional days are authorized before an out-of-area member is discharged.

  • Within 48 hours, notify of any changes to the original pre-service review.
  • Within 72 hours, notify of any urgent/emergent inpatient admission.
If a provider fails to obtain preapproval within the time frames outlined, the Home Plan may deny the entire claim (i.e., 100 percent sanction). In some cases, the Home Plan may still apply a 100 percent sanction even if the provider obtains a retrospective authorization.

Please also note the following:

  • 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 the preapproved length of stay, any additional days should be approved no later than the last day of the originally preapproved time period. For example, if five days are approved by the Home Plan, the provider should contact the Home Plan and ask to have the authorization updated by no later than the fifth day if the patient has not been discharged by that time. Please ensure that you seek approval of additional days to avoid claim denials or penalties.
  • 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.

Get preapproval electronically

Use the NaviNet® web portal to access the provider portal of an out-of-area member?s Home Plan and conduct electronic pre-service reviews. The PreService Review for Out of Area Members transaction is available under the Blue Exchange® Out of Area option in the Independence Workflows menu. For instructions on how to use this transaction, refer to the user guide available in the NaviNet Resources section. If you have any questions, please call the eBusiness Hotline at 215-640-7410.

Please note that providers may still need to call the member?s Home Plan to request preapproval if the Home Plan does not offer electronic pre-service review. Providers can call the BlueCard Eligibility® line at 1-800-676-BLUE and ask to be transferred to the utilization review area.

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