Preauthorization for inpatient elective admission
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This document governs preauthorization requirements for inpatient and observation hospital admissions for Capital Blue Cross members, specifying when prior authorization is required and how to submit requests; it affects providers requesting inpatient elective admissions and related services.
No material clinical or coverage changes in this revision.
Preauthorization and Admission Criteria
Preauthorization criteria and submission process
Covered when ALL of the following are met:
ALL of the following
- Place of service (Hospital or Other), admission date and end date, and requested units/days.
- Primary diagnosis and any additional diagnoses.
- Primary procedure/HCPC codes (when applicable).
ALL of the following
- Most recent history & physical (H&P).
- Progress notes and diagnostic studies.
- Photographs, molds, or other relevant supporting materials as applicable.
Codes and Observation Thresholds
| Primary procedure/HCPC codes | Request form requires listing primary procedure or HCPCS codes when applicable |
Preauthorization Process & Contact Information
Prior Authorization Required for Inpatient Admissions
Preauthorization is required for inpatient hospital admission requests when the procedure meets CMS inpatient-only guidelines for Medicare Advantage members or InterQual guidelines for Commercial members. Observation stays of up to 48 hours do not require preauthorization.
- Inpatient elective admissions: Preauthorization required when inpatient-only per CMS (Medicare Advantage) or per InterQual (Commercial).
- Observation stays <= 48 hours: Preauthorization not required.
Submission & Contact Information
Requests may be submitted by fax, phone, or mail. Fax the completed preauthorization form to 717.651.8966. For questions or to contact Utilization Management, call 800.471.2242. Mail Capital Blue Cross letters of medical necessity and supporting documentation to: UM Department, Capital Blue Cross, PO Box 773731, Harrisburg, PA 17177-3731.
- Fax: 717.651.8966
- Phone (Preauthorization/UM inquiries): 800.471.2242
- Mail: UM Department, Capital Blue Cross, PO Box 773731, Harrisburg, PA 17177-3731
Urgency Levels (Standard vs Expedited)
Designate the urgency when submitting authorization requests. Standard (routine) requests are for non-emergent care. Expedited (urgent) requests are for emergent situations where a delay could seriously jeopardize the life, health, or safety of the member, or where, in the practitioner’s opinion, applying the standard timeframe would subject the member to adverse health consequences.
- Standard request: routine care that is not emergent, urgent, or preventive.
- Expedited request: emergent/urgent care where delay could seriously jeopardize the member’s life, health, or safety, or where the practitioner believes waiting would cause adverse health consequences.
Key Definitions
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