December 2016

Effective Jan. 1, 2017 – Notification for Post-stabilization Care Following an Emergency Admission is Required

Notification of admission for post-stabilization care services following an emergency admission allows Blue Cross and Blue Shield of Texas (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 through BCBSTX, such as Case Management or service/care coordination.

Notification also allows BCBSTX to assist members with discharge planning. Thus, for stabilized members, BCBSTX requires notification of admission for post-stabilization care services within one business day following treatment of an emergency medical condition.

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, charges for which cannot be billed to the member pursuant to your provider agreement with BCBSTX. In the event of a claim denial that includes emergency care services, the provider is instructed to rebill the claim for the emergency services (including stabilization services), as well as post-stabilization care services. You can submit a notification for post-stabilization care services through our secureprovider portal, Availity^® or via iExchange^®, or by phone using the number on the member’s ID card. Timely post-stabilization notification of inpatient admission does not guarantee that it meets medical necessity.

Availity is a registered trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.