Guidelines for Observations and Acute Inpatient Hospital Admissions

Contracted facilities must notify Blue Cross and Blue Shield of Nebraska (BCBSNE) Care Management of all admissions and provide clinical information within one business day of the admission. Timely notification helps ensure that Medicare Advantage members receive care in the most appropriate setting, that BCBSNE Care Management is involved in the evaluation and coordination of discharge planning and that there are appropriate referrals to case management for members who need those services, including those managing complex and chronic disease processes, demonstrating high use of health resources and who are at high risk for health complications.  

BCBSNE Care Management nurses conduct admission and concurrent reviews via telephone or fax by obtaining information from the hospital’s utilization review staff. Care Management nurses also speak to attending physicians when necessary to obtain information.  

Clinical information includes relevant information about the member regarding the following: 

• Health history 
• Physical assessment  
• Test and laboratory results  
• Consultations  
• Emergency room treatment and response  
• Admitting orders  

NOTE: A copy of the form used to submit clinical information for Inpatient acute can be found on BCBSNE website: NebraskaBlue.com/Providers/Policies-and-Procedures/Medicare-Advantage-Policies. This form also includes required documentation for readmissions within 30 days of discharge from the initial admission with the same or a similar diagnosis.  

Once authorization is attained, the facility will be provided with an authorization number that is valid for the entire length of stay for the acute care admission.