Clinical Review of Inpatient Services

For the most current list of Medical requiring clinical review visit MedPolicy Blue.   

Providers are advised to submit clinical information via fax or phone for elective acute care admissions, skilled nursing facility, long term acute care facilities, inpatient rehabilitation facilities requests prior to the start date. Providers are advised to submit clinical documentation via NaviNet^® or phone on the next business day for all urgent acute care admissions. 

Providers will have access to form templates, which identify the specific information required to process a service request via NaviNet. 

*Note - BCBSNE does not impose any administrative denials for failure to comply with the notification timeframes. Post service requests will be processed, and decisions are based on medical necessity and the member’s benefit coverage only. 

If the nursing clinical review staff is unable to approve the request for inpatient services, the request is referred to a plan medical director for review. 

When the plan medical director is unable to approve the service a denial notification is sent to the member, provider and practitioner. The denial notification includes:

• Description of the criteria utilized to render the determination 
• Reason for the denial 
• Right to request the criteria used to render the decision 
• Right to request the diagnosis and procedure codes related to the request 
• Description of how to file an appeal 
• Availability of a plan medical director to discuss the individual merits of the case  

The clinical staff also reviews requests that require a benefit determination. If the service is not a covered benefit, the clinical staff denies the request. The denial notification includes the specific location in the Evidence of Coverage that describes the exclusion as well as the member appeal rights. 

All decisions are made and notifications are provided in compliance with state and federal laws, regulations and accreditation standards. A plan medical director makes all denial determinations based on medical necessity.