Updated Oct.28, 2021
This accommodation ended October 31, 2021. We will continue to evaluate and update, if needed.
Blue Cross and Blue Shield of Texas (BCBSTX) is making it easier to transfer our members from acute-care facilities to in-network, medically necessary alternative post-acute facilities through Oct. 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:
- Self-funded group
- Medicare Advantage
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 Texas 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 Oct. 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.
Because this is a rapidly evolving situation, you should continue to use the Centers for Disease Control Guidance (CDC) on COVID-19, as the CDC has the most up-to-date information and recommendations. Additionally, watch for updates on BCBSTX News and Updates and our COVID-19 Preparedness pages.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.