Clinical review requirements suspended until further notice for certain hospitals at higher inpatient bed occupancy

Due to the recent surge in COVID-19 cases, Blue Cross Blue Shield of Michigan and Blue Care Network are temporarily suspending clinical review requirements for all non-elective medical cases for those hospitals most impacted by the pandemic.

Effective Nov. 25, 2020, and until further notice, the following changes apply to Michigan hospitals with a bed occupancy of 85% or higher*. These changes apply to all lines of business, including Blue Cross commercial, Blue Care Network commercial, Medicare Plus BlueSM and BCN AdvantageSM:

  • Clinical review requirements for all non-elective medical cases will be suspended in hospitals with inpatient bed occupancy at 85% or higher.

    *Blue Cross and BCN are evaluating hospital occupancy each Wednesday based on the previous week's data from the Michigan Department of Health & Human Services. This information can be found on the Statewide Available PPE and Bed Tracking webpage** on the Michigan.gov website (see the Patient Census chart at the bottom). Non-elective medical cases will auto-approve beginning on the Monday following Blue Cross and BCN's evaluation. Once a hospital falls below the 85% bed occupancy rate for three consecutive weeks, non-elective medical cases will no longer auto-approve. Please see the Temporary suspension of clinical review requirements document for hospitals who have the clinical review requirements suspended each week. This document can be found within Provider Secured Services by clicking Coronavirus (COVID-19). It is posted under the Utilization management section.

  • Admissions to skilled nursing facilities from the hospitals that qualify for accommodations based on bed occupancy will auto-approve the first three days.
  • Long-term acute care hospital and inpatient rehabilitation facility admissions from the hospitals who qualify for accommodations based on bed occupancy will receive expedited processing with most decisions made within two hours of the request for discharge during normal business hours. Clinical review is still required.

    • Note:

  • Non-elective admissions with suspended clinical review may be subject to a future audit.
  • Hospitals and facilities that qualify for accommodations based on bed occupancy must still submit a plan notification, so an authorization is in our system when we receive the claim. A plan notification is a request for authorization submitted through e-referral for which no clinical documentation is required.
  • Hospitals are encouraged to submit plan notifications through the e-referral system.
  • Skilled nursing facilities that receive an admission from a hospital that qualifies for accommodations based on bed occupancy are not required to submit clinical documentation until the continued stay review, starting on the fourth day of stay.
  • These changes do not apply to elective procedures or outpatient services. All other prior authorization requirements continue.
  • These temporary changes do not apply to FlexLink® groups for which a third-party administrator makes authorization determinations. Facilities should check the back of the member's ID card to determine whether a third-party administrator needs to be contacted prior to an admission.

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