Temporary Replacement of Prior Authorization with Notifications for Certain Services
It is anticipated that North Carolina hospitals will see a surge of patients in the next two weeks during the peak of the COVID-19 pandemic. To help ensure access to care for our members, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will temporarily suspend the following, for in-network providers located in North Carolina:
- the requirement that providers obtain prior authorization for medically necessary emergent non-elective inpatient admissions and post-acute care services.
- concurrent review for appropriateness on inpatient acute care hospital admissions.
This temporary change will remain in place for 14 days during the forecasted surge of hospital admissions in North Carolina, which is anticipated to begin on April 9, 2020 and continue through April 22, 2020. Blue Cross NC will update this time-frame if the surge changes from its current forecast or the period needs to be extended based on hospital capacity.
24-Hour Notice Requirement
In place of prior authorizations, Blue Cross NC will require notification by the provider within 24 hours of such service or hospital admission. Such admissions and services remain subject to Blue Cross NC’s medical policy guidelines, but providers will not be required to send medical records to Blue Cross NC for prior review. Blue Cross NC will continue to enforce prior authorization requirements for non-emergent and elective procedures.
This will apply to:
- individual, under-65 customers
- fully-insured group customers
- State Health Plan customers
- self-funded (ASO) group customers
- Medicare customers
- Blue Cross NC members who see providers and hospitals in identified COVID-19 “hot spots” across the country (NOTE: Blue Cross NC will work with these providers and hospitals and apply these temporary measures in these areas where possible.)
This will not apply to:
- Federal Employee Program customers
- Blue Card Host members (members of other Blue Cross and Blue Shield plans who visit providers in North Carolina)
- Blue Cross NC members receiving care out of state, unless the care is with providers and hospitals in identified COVID-19 “hot spots” across the country. We will apply these temporary measures in those areas where possible.
Questions and Answers
Why is Blue Cross NC doing this?
- Blue Cross NC is committed to helping members get the quality, affordable care they need. Part of that means supporting our front-line health care workers and ensuring access to care.
- It is anticipated that North Carolina hospitals will see a surge of patients in the next two weeks during the peak of the COVID-19 pandemic.
- The COVID-19 crisis is requiring everyone in the health care community to work together and do their part. Blue Cross NC is taking steps to help our members prepare, stay healthy and get the care they need. We will continue to respond to this crisis to best serve our members and employers.
What financial impact can self-funded groups expect to see as a result of these measures?
Blue Cross NC does not estimate the financial impact of this temporary utilization management change to be material to the inpatient costs of any of our self-funded customers. This is largely because the work these health systems are performing currently is almost exclusively related to the COVID-19 surge and urgent triaging that will need to take place.
Does this apply to members with and without a COVID-19 diagnosis?
What services will not require a prior authorization?
During this temporary surge period, for certain services provided by in-network providers in North Carolina, Blue Cross NC will require notification only, and not request prior authorization, for medically necessary, emergent non-elective inpatient admissions and post-acute care services.
This may include:
- Emergency medical and behavioral health inpatient levels of care (including acute, Long Term Acute (LTAC), Acute Inpatient Rehabilitation (AIR) subacute rehabilitation (Rehab), and Skilled Nursing Facility (SNF).
- Home Health (HH) services
Prior authorization requirements will continue for other services as normal, including elective surgery.
What services will not require concurrent review for appropriateness?
During this temporary surge period, and for the applicable members, concurrent review for appropriateness will be suspended for inpatient acute care hospital admissions. For other levels of care, concurrent review will continue. (This includes services provided at inpatient rehabilitation centers, long term acute hospital, and skilled nursing facilities.)