New Response Time for Inpatient Admission Length of Stay Extensions and Transfers

We recently received clarification from The National Committee for Quality Assurance (NCQA) that requests for transfer from one acute setting to another inpatient setting (e.g., Acute, Skilled Nursing Facility, Acute Rehab, Long Term Acute Care, or Hospice – dependent on policy benefits) should be handled within the urgent timeframes. Please note, the Federal Employee Program does not have a Skilled Nursing Facility benefit. Also, any length of stay (concurrent review) requests should be handled within the urgent timeframes.

When you make an authorization request for the request types listed above after October 3, 2016, and you fail to submit the supporting clinical information at the time of the request, a Blue Cross and Blue Shield of North Carolina (Blue Cross NC) representative will request the required clinical information within 24 hours of receipt of your request. This includes weekends and holidays. You will be provided a timeframe (specifically a date and time) for which the supporting clinical information must be submitted. This timeframe will be a minimum of 24 hours.  

If supporting clinical information is not submitted at the time of the initial request OR within the timeframe provided, we will make and notify you of our decision within 72 hours from receipt of your request.

If all clinical information needed to support the request is received at the time of the initial request, we will notify you of our decision within 24 hours of receipt of your request.

Once an admission is approved, Blue Cross NC may follow up with you regarding the patient's discharge planning and length-of-stay (concurrent review) needs. Concurrent review decisions also fall under the urgent timeliness standards.

This process change, which is effective October 3, 2016, affects Blue Cross NC's commercial, Federal Employee Program, and State Health Plan plans.

Why Is Blue Cross NC Making This Change?

We must comply with NCQA timeliness standards in order to remain accredited.

Tips to Ensure a Timely Response

While we hope you are pleased that our response to you will be quicker, we also recognize the challenges in getting this information to us in a shorter time frame or outside of your regular business hours.

Here are some tips that will help us work together to successfully process these requests and avoid unnecessary adverse determinations:

If notifying us by fax, please label your request (e.g. Inpatient Rehab, Acute to Acute Transfer, Long Term Acute Care, Skilled Nursing Facility, or length of stay extension) so that we can process them timely.

Please provide all necessary supporting clinical information at the time of the initial request. Missing or incomplete supporting clinical information is the main reason for delays in processing your requests and can result in an adverse benefit determination.

If Blue Cross NC notifies you that supporting clinical information is needed, please submit the clinical information as quickly as possible, but no later than the timeframe provided.

When notified that updated clinical information is needed for length-of-stay (concurrent review) needs, please respond to us within the timeframe provided.

Clinical information can be submitted to us via phone, fax, or ProviderLink (see contact information below).

Contact Information

Phone Number

Fax Number

Commercial

1-800-672-7897

1-800-571-7942 (Acute requests)

State Health Plan

1-800-672-7897

1-866-225-5258 (Acute requests)

Commercial and State Health Plan

1-800-672-7897

1-800-228-0838 (SNF, Rehab, LTAC, Hospice requests)

Federal Employee Program

 1-800-672-7897

Continue to use your assigned fax number

While providers can request a Provider Courtesy Review if an adverse determination is made, this process can be time-consuming for both parties. We strive to make the appropriate determination the first time; therefore, submitting complete and accurate information at the time of your request is critical.

Blue Cross NC's compliance staff will be monitoring this new process in order to assess compliance related to these new timeliness standards. It is our goal to be 100 percent compliant and to consistently strive to eliminate any barriers to meeting these timeliness goals.