December 2016

Reminder: Notification for Inpatient Admission for Post-stabilization Care Required Within One Business Day for Blue Cross Medicare Advantage (PPO)^SM and Blue Cross Medicare Advantage (HMO)^SM Members

Effective Jan. 1, 2017, Blue Cross and Blue Shield of Texas (BCBSTX) will require notification of inpatient admission for post-stabilization care within one business day following the treatment of an emergency medical condition. This requirement applies to Blue Cross Medicare Advantage (PPO) and Blue Cross Medicare Advantage (HMO) plans.

Post-stabilization notification of inpatient admissions allows BCBSTX to evaluate the appropriateness of the setting of care and other criteria for coverage purposes. It aids in early identification of members who may benefit from specialty programs available from BCBSTX, such as Case Management, Care Coordination and Early Intervention (CCEI), or Longitudinal Care Management (LCM).

Notification also allows BCBSTX to assist the member with discharge planning. Failure to timely notify BCBSTX and obtain pre-approval for further post-stabilization care services may result in denial of the claim(s) for such post-stabilization care services, which cannot be billed to the member pursuant to your provider agreement with BCBSTX. You can submit a notification for post stabilization care services through our secure provider portal via iExchange^®, or by phone, using the number on the member’s ID card. Timely post stabilization notification of inpatient admission does not guarantee payment.

In the event of a claim denial that includes emergency care services, the provider can rebill the claim for the emergency services (including stabilization services), as well as post-stabilization care services for which BCBSTX may be financially responsible for possible re-adjudication by BCBSTX.