Peer-to-peer review request process to change Jan. 4 for inpatient medical hospital admissions

Effective Jan. 4, 2021, the process for requesting peer-to-peer reviews for inpatient medical hospital admissions will change. Here are the changes that go into effect on that date:

• For Medicare Plus Blue^SM members, Blue Cross Blue Shield of Michigan will no longer accept peer-to-peer requests related to inpatient medical hospital admission denials.

Instead, facilities are encouraged to follow the two-level provider appeal process for Medicare Plus Blue to reevaluate the denial decision on an inpatient admission request. See the "Contracted MI Provider Acute Inpatient Admission Appeals" section in the Medicare Plus Blue PPO Manual (PDF).

• For our Blue Care Network commercial, BCN Advantage^SM and Blue Cross commercial members, we'll still accept peer-to-peer review requests. However, facilities must submit these requests within seven days of the date the initial authorization request was denied.

We're updating documents

We're updating the document titled How to request a peer-to-peer review with a Blue Cross or BCN medical director (PDF) to reflect the changes in the process for all lines of business.

The updated document will be available starting Jan. 4 on these webpages:

• BCN Authorization Requirements & Criteria webpage - Look under the Referral and authorization information heading
• Blue Cross Authorization Requirements & Criteria webpage - Located in both the Blue Cross PPO and Medicare Plus Blue PPO sections of the page

We're also updating the provider manuals to reflect the changes related to peer-to-peer-review request.

Guidelines for submitting clinical information

Follow these guidelines when submitting prior authorization requests for inpatient hospital admissions:

• Submit the request once the clinical documentation meets InterQual^® criteria.
• If InterQual criteria is not met, submit all the clinical documentation needed to support the medical necessity of the admission.

If a request is pended for clinical review, our clinicians will use the clinical information you've submitted to support a medical necessity determination.

How to expedite review of the authorization request

Here are some things you can do to expedite review of the authorization request and possibly avoid the need to request a peer-to-peer review:

• Attach all pertinent clinical information from the medical record to the authorization request to validate that an inpatient setting is appropriate.
• Submit only requests that have a complete set of clinical information.
• Clinical documentation must include:
  • The InterQual^® criteria subset you used to support the decision for inpatient admission
  • The pertinent clinical information that validates the InterQual criteria points that are met
  • The procedure code from the Centers for Medicare & Medicaid Services inpatient surgical list you used to support the decision for an inpatient admission