April 07, 2020
Updated Jan. 05, 2021
Updated March 11, 2021
Updated Oct. 12, 2021
Updated Oct. 25, 2021
Updated Dec. 1, 2021
This accommodation was reinstated on Sept. 30, 2021 and will expire on Dec. 31, 2021. Some timeframes have changed. We will continue to evaluate and update, if needed.
Blue Cross and Blue Shield of Montana (BCBSMT) is making it easier to transfer our members from acute-care facilities to in-network, medically necessary alternative post-acute facilities through Dec. 31, 2021.
We will no longer require a post-acute care facility to obtain prior authorization to transfer our members from an inpatient hospital to an in-network medically appropriate, post-acute site of care such as long-term acute care hospitals, skilled nursing facilities, rehabilitation facilities and in-patient hospice. The receiving facility must call and inform us of the transfer within two business days.
This will help promote availability of acute care capacity for COVID-19 patients during this Public Health Emergency. It also allows our members to continue to access medically necessary care. Coverage is based on the members’ benefits.
If the transfer is for a behavioral health facility, it will require prior authorization.
Which members will benefit?
This applies to the following members:
- Fully insured
- Self-funded group
- Medicare Advantage
- Healthy Montana Kids (subject to approval by local regulators)
It does not apply to Federal Employees Program members at this time.
How to Transfer a Member
You can move members who are medically stable for transfer to the safest, most appropriate in-network place of care. You do not need our approval for transfer to any Montana in-network, post-acute care facility that is:
- In-network consistent with the member’s plan (e.g. a PPO member could be transferred to an in-network PPO facility)
- Medically appropriate for the member and medically necessary
- Available and accepting transferred members
The receiving facility should notify us within two business days. Once our member is transferred, our standard utilization management processes will apply as described in more detail below.
Standard Utilization Management Process
After the post-acute care facility notifies us, our utilization management care manager will not review the admission for medical necessity. They will work with the post-acute care facility to:
- Approve the admission without records for the first two days
- Manage the ongoing stay for concurrent review
- Work with the facility for discharge planning
Post-acute care facilities must notify us of the admission, but they do not have to send records or wait for authorization before admitting our members.
How long is this process in effect?
The utilization management process modification will be in effect through Dec. 31, 2021. We will then determine if it needs to be extended to best serve our members.
- State and federal laws and regulatory requirements will supersede these guidelines.
- We maintain the right to retrospectively review health care services submitted for claims payment for accuracy and appropriateness.
- This change to member prior authorization requirements is subject to in-network facility access.
As a reminder, it is important to check eligibility and benefits before rendering services. This step will help you determine if benefit prior authorization is required for a member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section on BCBSMT’s provider website.
Please note that checking eligibility and benefits, and/or the fact that a service or treatment has been prior authorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card.