CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Hospital Utilization Review Requirements

Administrative requirements and procedures for participating hospitals in Rhode Island regarding utilization review, record sharing, and communication with Blue Cross & Blue Shield of Rhode Island (BCBSRI). Affects contracted hospitals and BCBSRI medical management staff.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHospital Utilization Review Requirements

Policy CodePolicy N/A

Change TypeInformational / Administrative

Effective DateN/A

Next Review DateN/A

Key ActionHospitals must provide concurrent medical updates and daily admission/discharge lists to BCBSRI and cooperate with onsite reviews and discharge planning.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysnotice period for material changes

dailyadmission/discharge reporting

dailyend-of-day adverse determination communication

InterQualutilization review guidelines

Coverage and Medical Criteria

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Hospital / Provider Operational Requirements

Documentation Required

Concurrent Medical Updates and Onsite Review

The hospital, through its utilization review staff, must provide concurrent medical updates to the BCBSRI designee upon request. BCBSRI may send a representative or an onsite nurse to the hospital for review of records, to attend conferences, and/or to participate in discharge planning meetings related to members. BCBSRI currently uses InterQual guidelines and will provide at least 60 days' notice before materially changing those guidelines or implementing new medical or administrative policies.

BCBSRI may request concurrent medical updates at any time during an admission.
BCBSRI may conduct onsite reviews and attend discharge planning or case conferences.
Hospitals must accept BCBSRI medical and administrative policies and will be given at least 60 days' notice prior to implementation.

Denial Risk

Denial Notification Process

BCBSRI's medical management team will make every effort to verbally notify the hospital's medical management team of potential denials. In addition, the BCBSRI onsite nurse documents adverse determinations on a written end-of-day communication sheet that is provided to the hospital Utilization Review/case management team and payer liaison for both Commercial and Medicare products. The hospital medical management team may discuss potential denials with the attending physician and must notify BCBSRI if concurrence on a less intensive level of care is reached; BCBSRI will keep the hospital informed of decisions reached after such discussions.

Verbal notification of potential denials will be made when possible.
A written end-of-day communication sheet will summarize any adverse determinations and be provided to hospital utilization review and payer liaison (see attachments A & B).
Hospitals should notify BCBSRI when agreement is reached with the attending physician on a less intensive level of care; BCBSRI will reciprocate with updates on final decisions.

Note

Daily Admission/Discharge Reporting

The hospital agrees to provide BCBSRI with daily admission and discharge lists. These daily reports facilitate timely utilization review and coordination between the hospital and BCBSRI.

Daily admission lists (including new inpatient admits) must be sent to BCBSRI.
Daily discharge lists (including patient discharges) must be sent to BCBSRI.

Definitions and Legal Authority

InterQual — current guidelines utilized by BCBSRI for utilization review

Current utilization review guidelinesInterQual

Notice period for material guideline changes60 days' notice to hospitals before implementation

BCBSRI authority for utilization reviewOperates under The Utilization Review Act (RIGL 23-17.12)

Legal authority — The Utilization Review Act (RIGL 23-17.12)

Statutory authorityThe Utilization Review Act (RIGL 23-17.12)

Scope under statuteAuthorizes BCBSRI to perform utilization review of hospital admissions in Rhode Island

Related hospital obligationsHospitals must provide concurrent medical updates and allow BCBSRI representatives to review records and attend conferences/ discharge planning meetings

OpenPayer

Hospital Utilization Review Requirements

Coverage and Medical Criteria

Billing and Code References

Hospital / Provider Operational Requirements

Definitions and Legal Authority