Updated: More COVID-19-related utilization management changes

We've updated this news item, which was first published on May 26, 2020. The new date on which clinical review is again required for acute care admissions with non-COVID-19-related diagnoses is June 13, 2020. (We had previously announced the date was June 1, 2020.) Please use this news item as the most current source of information on these changes.

Over the past few weeks, Blue Cross Blue Shield of Michigan and Blue Care Network implemented utilization management changes aimed at supporting our providers during the COVID-19 emergency.

We're making additional utilization management changes at this time.

Here are the important things you need to know.

Temporary change ending: Waiving of clinical review requirements for acute care admissions with non-COVID-19 diagnoses

Starting June 13, 2020, clinical review is again required by Blue Cross / BCN Utilization Management for acute care admissions with non-COVID-19-related diagnoses. This means you'll need to submit clinical documentation along with your authorization requests.

Note: For admissions with COVID-19-related diagnoses, see the section titled "Changes extended temporarily," below.

Changes extended temporarily, through June 30, 2020:

• For acute care admissions with COVID-19-related diagnoses, no clinical review is required. However, you must still continue to notify the plan (that is, you must submit an authorization request without clinical documentation).
• For CT scans of the chest to rule out pneumonia diagnosis associated with COVID-19, AIM Specialty Health does not require clinical review for procedure codes *71250, *71260 and *71270. You only need to notify AIM Specialty Health^®.
• For the first three days of admission to a skilled nursing facility for members transferred from acute care, Blue Cross / BCN Utilization Management and naviHealth do not require clinical review. However, you must notify Blue Cross / BCN (by submitting the authorization request with no clinical documentation) or naviHealth (by contacting navIHealth prior to transferring the member).

Starting July 1, 2020, you must submit clinical documentation along with your authorization requests for the acute care admissions, CT scans and SNF admissions described in this section.

Change in the duration of authorization approvals for elective and non-urgent services

For elective and non-urgent services:

• All authorizations approved on or before May 25, 2020, will be valid through Dec. 31, 2020.
• All authorizations approved on or after May 26, 2020, will also be valid through Dec. 31, 2020. Exception: For authorizations approved with an end date that goes beyond Dec. 31, the end date identified in the authorization approval will be honored.

This applies to authorizations approved for in-state and out-of-state providers on or after the following dates:

• Blue Cross / BCN Utilization Management: March 13, 2020
• AIM Specialty Health: April 6, 2020
• eviCore healthcare: March 26, 2020

This doesn't apply to Flexlink^® groups for which a third-party administrator makes authorization determinations. Contact the third-party administrator on the back of the member's ID card for instructions.

Additional change: Turnaround time on post-acute care determinations

naviHealth will make a same-day determination on all Medicare Advantage post-acute care requests and, for certain admissions to SNFs, will implement an expedited review process. Due to increased workloads, naviHealth is no longer able to make a determination on these requests within two hours.

Both Blue Cross / BCN Utilization Management (for commercial members) and naviHealth (for Medicare Advantage members) will continue to assist providers in locating post-acute care providers, especially for difficult transitions.

More information

The information in this message has been added to the COVID-19 utilization management changes (PDF) document, which you can access on this website, on the Blue Cross Authorization Requirements & Criteria page and the BCN Authorization Requirements & Criteria page.

This information applies to the following members, unless otherwise noted:

• Blue Cross' PPO (commercial)
• BCN HMO^SM (commercial)
• Medicare Plus Blue^SM PPO (Medicare Advantage)
• BCN Advantage^SM (Medicare Advantage)

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.

Posted: May 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network