2015 CURP Facility Resource Manual - June 2015
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2015 CURP Facility Resource Manual June 2015
Table of Contents
Introduction 4
• Roles and Responsibilities 4
o Blue Cross Clinical Auditor 4
o Facility CURP Coordinator/Utilization Reviewer 4
o Blue Cross Member Management (Case Management) 5
o Peer Clinical Reviewer (PCR) 5
o Provider Network Services Representative 5
Contact Information 6
• Blue Cross and Blue Shield of Alabama Provider Web Address 6
• Provider Inquiry/Provider Services 6
• Website Support 6
• Provider Network Services 6
• Network Clinical Unit 7
• Member Management/Disease Management 7
• Peer Clinical Review 7
• Special Employer Groups 8
Concurrent Utilization Review Program 9
• Medical/Surgical Review Guidelines 9
o Medical/Surgical Review Processes 9
o Medical/Surgical Facility Transfers 11
o Procedural Length of Stay Guidelines 11
o Pre-operative Day Guidelines 11
o Newborn Review Guidelines 12
o Tips for Criteria Application 12
• Observation Guidelines 13
Blue Advantage 14
Federal Employee Program (FEP) 15
Peer Clinical Reviewer (PCR) Physician Referral Process 16
Appeal Process 17
CURP Resources 19
• Local (Organizational) Policies/McKesson’s Informational Notes 19
• CURP Publications 19
o CURPFacts/CURP Flash/CURP Facility Resource Manual 19
• InterQual Resources 19
Terminology/Definitions 20
Forms/Web Links 20
2015 CURP Facility Resource Manual Page 2Disclaimer The following disclaimer is applicable to all telephone inquiries and automated communications systems to Blue Cross and Blue Shield of Alabama: The information provided is only general benefit information and is not a guarantee of payment. Benefits are always subject to the terms and limitations of the plan and no employee of Blue Cross and Blue Shield of Alabama has authority to enlarge or expand the terms of the plan. The availability of benefits is always conditioned upon the patient’s coverage and the existence of a contract for plan benefits as of the date of service. A loss of coverage, as well as contract termination, can occur automatically under certain circumstances. There will be no benefits available if such circumstances occur. McKesson’s InterQual® Criteria McKesson Corporation and/or one of its subsidiaries is the owner/licensor of the InterQual® Criteria. The criteria is protected under United States and international copyright and other intellectual property laws. Blue Cross and Blue Shield of Alabama licensed InterQual Criteria is to be used solely for its members. Use of "Physicians' Current Procedural Terminology," (CPT®) CPT codes copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Note: Please refer to our website, AlabamaBlue.com/providers, for the most current benefit and policy information. 2015 CURP Facility Resource Manual Page 3
Introduction
The Concurrent Utilization Review Program (CURP) is a partnership between Blue Cross and
Blue Shield of Alabama and participating hospitals. The goal of CURP is to ensure appropriate and
efficient use of hospital services while maintaining high-quality patient care. This manual should
be used in conjunction with McKesson’s InterQual® criteria to perform delegated review activity.
Organizational or local policies have been entered into the Web portal InterQual Criteria and
identified with a yellow “P.”
Facilities are delegated to perform CURP reviews for medical admissions. All behavioral health
services are now certified through our vendor, New Directions Behavioral Health (NDBH). Any
admission filed with a behavioral health diagnosis code as the primary diagnosis will require a
certification from NDBH. To contact a NDBH representative, call 1-855-339-8558 or log in to
NDBH.com. Select “I am a provider” and use the “WEBPASS” link to complete admission forms.
Precertification (1-800-248-2342) is required if the facility is not CURP delegated for a specific
diagnosis or if the admitting physician is not a participating Preferred Medical Doctor (PMD) provider
and is admitting a patient for an elective admission. Non-PMD physician urgent admissions do not
require precertification.
In participating hospitals, the delegated Utilization Reviewer designated to carry out the medical
utilization review process is a Registered Nurse (RN) or Licensed Practical Nurse (LPN). In performing
utilization review, all pertinent information documented in the medical record is reviewed, including
patient history, medical condition, reason for hospitalization and acuity versus the chronicity of the
condition. Utilization review activities include identification of post-hospitalization requirements, along
with appropriate referrals to personnel within the hospital and the Blue Cross Member Management and
Disease Management Programs. Guidelines for referral to these programs are contained in this manual.
The information in this manual is composed for CURP activities. For more facility-specific information
regarding delegation of reviews, contact the facility assigned Clinical Auditor. For general information
about coverage or claim filing, please refer to the Blue Cross website at AlabamaBlue.com/providers.
Roles and Responsibilities
Blue Cross and Blue Shield of Alabama Network Clinical Unit (NCU) Clinical Auditor
Responsibilities of the Blue Cross Clinical Auditor:
• Acts as a general resource person for the hospital CURP staff
• Communicates pertinent information regarding changes in the CURP program to the hospital
• Conducts retrospective medical record audits to verify appropriate administration of the CURP
program and reports findings to the CURP Coordinator
• Identifies and collects refunds for non-certified or non-covered hospital days
• Conducts reviews for medical necessity appropriateness based on data
• Evaluates, monitors and provides feedback on reporting data of delegated entities per policy and
procedure
• Evaluates and provides oversight of CURP Facility Quality Improvement (QI) process
Facility CURP Coordinator/Facility Utilization Reviewer
Responsibilities of the Facility CURP Coordinator/Utilization Reviewer:
• Conducts initial review of all Blue Cross admissions within 24 hours or the first business day
following the admission
• Performs continued stay review and certification of hospital days in 24 hour increments from
admission through discharge based upon InterQual acute criteria
2015 CURP Facility Resource Manual Page 4• Contacts a Clinical Auditor concerning any patient that does not meet criteria, but is clinically
unstable, before referring to Peer Clinical Reviewer (PCR)
• Refers to a PCR days that do not meet InterQual Criteria, preoperative days not listed in this
manual, quality of care issues, or any delays in service
• Provides Blue Cross non-certification letters to members and explains accordingly
• Concurrently submits patient-signed copies of non-certification letters to Blue Cross
• Communicates with responsible hospital staff any indicated review findings to facilitate accurate
billing (e.g., observation versus inpatient status, non-covered days, etc.)
• Refers appropriate patients to Blue Cross Member Management/Disease Management
• Provides patient education regarding the Blue Cross CURP program
• Monitors the CURPFacts and CURP Flash publications for updates in CURP processes and
procedures
• Participates in educational updates provided by Blue Cross
• Notifies the Clinical Auditor of changes in hospital administration, CURP Coordinator and
utilization review staff conducting Blue Cross reviews
• Performs ongoing quality improvement process related to CURP activities
Blue Cross and Blue Shield of Alabama Member Management (Case Management)
Member Management is a voluntary program that is part of Blue Cross and Blue Shield of Alabama
contracts.
• This program provides a Care Coordinator (nurse) to evaluate patients with complex and/or
acute needs and assists with coordination of services.
• Care Coordinators also promote seamless transition from the acute inpatient setting to the next
level of care and assist members in the recovery process through education, medication
reconciliation, emotional support and identification of resources to meet individual needs.
• Specialty Care Coordinators are available for individual needs such as complex medical/surgical
conditions, high-risk pregnancy, pediatrics, organ transplant, rehabilitation, psychiatric and
substance abuse.
• Member Management Care Coordinators strive to reinforce the patient’s plan of care and to
support each facility in their efforts to reduce avoidable readmissions.
Peer Clinical Reviewer (PCR)
Healthcare professionals who conduct peer clinical reviews are qualified to render clinical determinations
regarding medical conditions, procedures and treatments under review. Peer Clinical Reviewers are
available to discuss determinations with attending physicians or other ordering providers when requested
by the attending or ordering provider within the allowed timeframe noted on the non-certified
determination letter. Peer Clinical Reviewers conduct reviews for:
• Cases in which services are delayed
• Preoperative days
• When criteria are not met
• Quality issues
Provider Network Services Representative
Provider Network Services Representatives are available to assist with the following:
• Education and training about Blue Cross programs
• Information for providers concerning plan procedures and policies through Town Meetings
and workshops
• Physician and hospital claim filing updates and changes
• Requirements for compliance with rules and regulations of the plan
• Problem identification and resolution
2015 CURP Facility Resource Manual Page 5Contact Information
Blue Cross and Blue Shield of Alabama Provider Web Address:
AlabamaBlue.com/providers
Provider Inquiry/Provider Services
CURP General Provider Inquiries:
• Regular Business: 1-800-760-6852
• Interactive Voice Response (IVR) only: 1-800-648-9807
• IVR with representative availability for providers who do not have access to the toll-free
number: 205-988-2213
Other Provider Inquiries:
• Blue Advantage: 1-800-517-6425
• FEP: 1-800-492-8872
• Non-PMD elective admissions: 1-800-248-2342
• Non-CURP delegated behavioral health: 1-800-248-2342, option 3
Out-of-State plans:
• Refer to the telephone number printed on the back of member’s identification card
Website and ProviderAccess Website Support
Call or email the website Support Center at 205-220-6899 or Ask-EDI@bcbsal.org if you:
• Cannot access our Blue Cross website, but you can access other websites
• Receive a system error while trying to sign into ProviderAccess, our secure section of
the website
• Forget your user ID and/or password
• Need assistance with access to any of the ProviderAccess applications or if an application is
slow or does not appear to work correctly
Provider Network Services
Network Services Representative (Healthcare Networks Representative)
Each representative has been assigned a specific geographic area to service. Since more than one
representative is responsible for Jefferson and Shelby counties, these counties are divided by zip codes
and hospitals. These lists are subject to change.
To find your Network Services Representatives visit AlabamaBlue.com/providers:
• Scroll to Provider Help and select “Contact Us”
• Scroll to Network Services and select “Locate your Network Services Representative by
territory”
• Select your state
• Select your county
2015 CURP Facility Resource Manual Page 6Network Clinical Unit
Telephone
Manager Number Fax Number E-Mail Address
Jan Dodson 205-220-3302 205-733-7265 jdodson@bcbsal.org
Clinical Auditors
Cynthia Barr 205-220-3814 205-733-7265 cbarr@bcbsal.org
Sandra Clifton 205-220-3140 205-733-7265 sclifton@bcbsal.org
Janice Davis 205-220-5010 205-733-7265 jddavis@bcbsal.org
Benjamin Dickson 205-220-6549 205-733-7265 bdickson@bcbsal.org
Connie Green 205-220-4902 205-733-7265 cgreen@bcbsal.org
Michelle Ingram 205-220-5019 205-733-7265 mingram@bcbsal.org
Lynne (Kerstan) Kilgore 205-220-3108 205-733-7265 kkilgore@bcbsal.org
Lila Killian 205-220-5013 205-733-7265 Lila.Killian@bcbsal.org
Kathryn (Jeanette) Marsac 205-220-2967 205-733-7265 kmarsac@bcbsal.org
Debra Meggs 205-220-2653 205-733-7265 dmeggs@bcbsal.org
Angie Shula 205-220-3146 205-733-7265 Angela.Shula@bcbsal.org
Badnette Tyus 205-220-5030 205-733-7265 bdtyus@bcbsal.org
Support Staff
Felicia Kelley 205-220-6845 205-220-0113 fykelley@bcbsal.org
Tameka Oden 205-220-2357 205-220-0113 toden@bcbsal.org
Administrative Coordinator
Mylenda Rushing 205-220-3089 205-733-7265
Member Management (Case Management)/Disease Management
Member Management/Disease Management Referrals (Medical/Surgical and Behavioral Health)
• Telephone: 1-800-821-7231 or 205-733-7067
• Fax: 1-855-312-0130
Member Management/Disease Management Referrals (Inpatient Physical Rehabilitation)
• Telephone: 1-800-821-7231 or 205-733-7067
• Fax: 1-866-443-0694 (prior to admission)
Member Management Referral Criteria List
When a referral to case management is submitted via the Web portal, supporting clinical documentation
must be faxed as a follow-up to the referral utilizing the fax coversheet link below.
Member Management/Disease Management Referral Form
Peer Clinical Review
PCR Referrals (Medical/Surgical)
• Contact your Clinical Auditor for fax coversheets
2015 CURP Facility Resource Manual Page 7Special Employer Groups
This information is provided as a guide. Group-specific information is subject to change. Refer to the
back of the member’s identification card for specific guidelines. Pended status in Web portal may be
applied per group instructions (e.g., Blue Advantage®).
CM Referral
Group Web Portal
Contact Information PCR Referral 1-800-821-7231/
Name/Prefix Entry
205-733-7067
Blue Advantage- Provider Services (PS): YES – Enter ALL Completed by CM: 1-888-341-5030
MBG 1-800-517-6425 inpatient Blue
admissions, Advantage If the admission does
Fax: 1-888-243-0031 including CM not meet inpatient
Procedural Length criteria, contact a
of Stay (LOS) list Blue Advantage CM.
admissions.
Admission Admission
Review Only Day Only
Federal PS: 1-800-492-8872 Admission Admission Refer for DC
Employee Review Only Day Only planning
Program Fax: 205-220-0859 needs/assistance
(FEP)
R Prefix Behavioral Health Refer ALL at
(>65 years and (BH): five days
retired and no New Directions
Medicare Part 1-855-339-8558
A)
FEP-R PS: 1-800-492-8872 YES YES Refer for DC
Prefix (not planning
retired) Fax: 205-220-0859 needs/assistance
BH: Refer ALL at
New Directions five days
1-855-339-8558
ADT-KYI PS: 1-800-517-6425 YES YES Refer for DC
General planning
Dynamics- needs/assistance
GKN, PRK
Genuine Parts Refer ALL at
Company-GPT five days
Lowes-LWE
Southern
Company-SCY
VF
Corporation-
EVF
State of Department of NO NO NO
Alabama Corrections telephone
Prisoners-XAJ number provided upon
admission
2015 CURP Facility Resource Manual Page 8Concurrent Utilization Review Program (CURP)
In support of CURP, Blue Cross provides our participating facilities access to InterQual Criteria and
educational supportive functions, via the ProviderAccess Web portal at AlabamaBlue.com/providers.
Each facility reviewer participating in utilization activities is assigned an identification number and
password, which may be changed periodically. It is the responsibility of the delegated facilities to
identify members appropriate for utilization review activity and entry into the Web portal. Web portal
entry is not a guarantee of payment.
Benefit coverage for acute care hospitalization is based on the medical necessity of the hospitalization
and contract coverage at the time services are rendered. Benefit coverage for acute care hospitalization
may be non-certified due to a lack of medical necessity for the acute care setting, untimely
services/testing, delays in scheduling tests/procedures/consultations, delays in discharge planning or
referrals to appropriate facilities for post-hospitalization services, excessive preoperative days and
benefit exclusions.
Blue Cross may not contract with all employer groups to perform utilization review for their members.
Facilities should identify non-Blue Cross review agencies by accessing the telephone numbers on the
back of the members’ card. Clinical information may be reported to these agencies.
The CURP review process and Web portal entry include InterQual Criteria pertinent to inpatient general
medical, surgical and observation episodes of care. Reviews should be conducted the first business day
following hospital admission. Continued stay review occurs cyclically throughout the hospital stay,
based on clinical condition and criteria. All inpatient dates of service must be reviewed using the
appropriate InterQual Criteria and guidelines outlined in the review process. Facility claims should
match diagnoses and criteria used.
Medical/Surgical Review Guidelines/Process
InterQual Level of Care Criteria products:
• Provide clinically relevant, evidence-based guidelines for determining the appropriateness of
hospital admission, continued stay and transition of care
• Methodology supports utilization management, case management and transition of care
• Contain clinical criteria organized into major levels of care that contain body system/treatment
or diagnostic subsets
• Present specific criteria points and sub-points in a decision-tree format
The two InterQual products used for medical patients include:
• Adult Acute Care Criteria ≥ 18 years
• Pediatric Acute Care Criteria < 18 years
When a hospitalized patient’s birthday occurs during a stay causing their age to change from 17 to 18
years old, the most appropriate product may be selected to complete the review.
Levels of care (LOC) provide criteria indicators of acuity and are specific to each InterQual product.
See McKesson’s InterQual Review Process for details.
2015 CURP Facility Resource Manual Page 9Admission Reviews are conducted for Episode Day 1 to determine the appropriateness of admission to
the inpatient level of care.
• Select appropriate criteria points from any level of care using clinical findings and treatments
pertinent to the medical condition/diagnosis.
• All available clinical information may be used, (e.g., ambulance notes, physician office
documentation, ER).
• The reviewer has 24 hours to collect all clinical information to make a determination.
• Admission time starts when first hands-on care is provided (e.g., triage, labs, x-ray, vital signs,
weighing patient).
• A late admission occurs when first hands-on care begins after 6 p.m. Combine day one and day
two of the admission into Episode Day 1 when admission occurs after 6 p.m.
• For obstetrical admission, approve two days for vaginal delivery and four days for cesarean
section.
• For surgical patients, post-surgical care begins upon transfer from the Post Anesthesia Recovery
Unit (PACU). For those patients who transfer directly to a unit bed from surgery, bypassing the
PACU, add one hour to surgical end-time to determine if the procedure qualifies as late (after
6 p.m.). This rule does not apply to elective procedures with recovery end-times after 6 p.m.
Continued Stay Reviews (CSR)
• CSR begin on Episode Day 2 and beyond, using clinical findings and treatments pertinent to
the medical condition/diagnosis to determine the medical necessity of continued stay and the
appropriate level of care.
• Only criteria for the specific episode day under review may be applied.
• Select appropriate criteria points from any inpatient level of care available on specific episode
days.
• All clinical data from 00:00 to 23:59 may be applied.
• Remain in Condition-Specific Subset (CSS) until episode days are exhausted or appropriate criteria
are no longer available.
• Extended Stay subset should be used once the episode days or endpoints within a condition-
specific or general subset have been exhausted and continued stay is necessary.
Responder Status is a description of the patient’s clinical response to treatment, available only during
continued stay review. Pertinent responder options are available on specific episode days. See
McKesson’s InterQual Review Process for details.
Criteria Point Rules/Guidelines
McKesson’s InterQual Criteria are organized around a predefined set of “rules.” To meet criteria, the
reviewer must select criteria points/sub-points as the rules specify. The rules apply to ALL episode
days. Criteria point rules such as “One,” “Two,” “Both” or “All,” tell how many criteria points/sub-
points a reviewer must select to fulfill the rule, and therefore, meet the criteria point. Requirements vary
according to the criteria subset. For example, in the rule of “One,” only one criteria point is required to
meet the rule.
Criteria Endpoint Rules indicate that the criteria may be used for no more than the specified time
frame. If criteria with end points are the same in multiple levels of care, the end point applies the day
the care was initiated, regardless of criteria verbiage “since initiation.” This includes the extended stay
subset. (Note: This is not a suggested length of stay, but defines the maximum time allowed for criteria
point application.)
2015 CURP Facility Resource Manual Page 10Medical/Surgical Facility Transfers
When a patient is transferred to a new facility and there is documentation of admission criteria being
met, an Episode Day 1 review is not necessary. The accepting facility should conduct the next review on
the appropriate episode day. Clinical information from the transferring facility may be used to meet
criteria.
Procedural Length of Stay (LOS) Guidelines
• The Procedural Length of Stay List (CPT Code Order or Body System Order) contains the
names of common surgical procedures with corresponding Physicians’ Current Procedural
Terminology (CPT) codes and the number of assigned hospital days.
• The day of surgery is included as the initial day in all LOS assignments.
• Patients remaining hospitalized beyond the assigned length of stay require continued stay
review.
• Procedures on the Possibly Non-Covered Procedure List may be considered cosmetic,
investigational, or non-covered and may require medical review.
Preoperative Day Guidelines
• In general, patients undergoing common, elective surgical procedures can be prepared safely for
surgery outside the hospital setting and admitted the day of surgery.
• See General Surgical subset local policies for approved preoperative days.
• For any other preoperative day requests not addressed in criteria, a PCR referral is required for
medical appropriateness. This referral must include:
o The physician’s name
o A medical history summary
o Date for which preoperative day is requested
o The physician’s plan of care
• Observation days may not be appropriate as preoperative days.
• Contact assigned Clinical Auditor for clarification.
Post-Surgical Care (See also Admission Review)
• Post-surgical care begins upon transfer from the Post Anesthesia Care Unit (PACU/Recovery
Room) on the day of surgery.
• If the patient was transferred directly from surgery to the nursing unit, add one hour to the
surgery end time. The Blue Cross Procedural Length of Stay List provides common surgical
procedures and preapproved lengths of stay.
• Add one day to the surgical length of stay for non-elective surgical procedures ending after
6 p.m.
• Criteria application is required as a continued stay review following the approved surgical length
of stay assignment.
• Continued stay review begins following the approved surgical length of stay.
• Continued stay reviews should be completed based on surgery category. Inpatient surgical
procedures are categorized in the General Surgical subset. See subset for details.
2015 CURP Facility Resource Manual Page 11Newborn Review Guidelines
• Routine care of normal newborns is covered along with the mother’s hospital stay.
• Federal law provides for a two-day stay for vaginal deliveries and a four-day stay for cesarean
section deliveries. An additional day may be assigned for late deliveries after 6 p.m.
• Web portal entry is not required for newborn stays occurring within these guidelines.
• It is appropriate to file a separate hospital claim and make a Web portal entry when the
newborn meets inpatient criteria and one of the following applies:
o The newborn is born ill and requires care beyond normal newborn care. If born ill
and requires care beyond normal newborn care, the newborn’s admit date is the date
of birth.
o The newborn becomes ill while the mother is still hospitalized and requires care
beyond normal newborn care. The newborn’s admit date is the date newborn
becomes ill and requires care beyond normal newborn care.
• Clinical criteria for the baby should NOT be entered into the Web portal under the mother’s
name. The newborn’s clinical information should be entered in a separate review.
• Contract numbers are not provided for newborns until the newborn is added to a contract.
• Newborns should be added to a contract within 30 days of birth.
Multiple Births
For multiple births, each newborn should be entered as a separate patient with its own review. A hospital
claim is submitted for each newborn’s hospital stay. In order to distinguish multiple newborns, use the
date of birth in the Patient SSN field, with a different last number to differentiate one newborn from
another.
Example: triplets born on January 15, 2014, enter Social Security numbers as follows:
Baby Boy1 – 011520141
Baby Boy2 – 011520142
Baby Girl – 011520143
Tips for Criteria Application
• “Pending culture” cannot be applied a second time for the same body system or condition. It
would be appropriate to apply pending culture if the patient developed a new condition or
symptom in a different body system (e.g., sputum culture for pneumonia).
• Anti-infective with “culture pending ≤ 2d” has an endpoint of two days. This rule indicates the
criteria point can only be applied for two days, beginning on the first day the treatment is
received. A third day may be added if the patient was admitted after 6 p.m., or if the treatment
was performed after 6 p.m. with no delay in rendering treatment or services.
• Relying on physician orders for treatment or services is a common review error. Documentation
must be present in the medical record that treatment or services ordered by the physician have
been provided.
• It would not be appropriate to apply DVT criteria for a non-obstructive small thrombus in a
superficial vessel, because the thrombus is not in a deep vein, but rather a superficial vein.
Consider observation status.
• Anticoagulants administered in the hospital setting must be administered at a therapeutic
dosage in order to meet this criteria point. Dosage is calculated based on body weight.
Prophylactic dosage does not meet criteria.
• It would be inappropriate to apply IV fluids with NPO status for a patient tolerating a clear
liquid diet.
• To apply the NPO criteria points, NPO status must be ordered as a treatment in response to
symptoms or findings and not as preparation for an upcoming test or procedure.
2015 CURP Facility Resource Manual Page 12• “Pain uncontrolled” has a rule of “BOTH.” The pain must be uncontrolled and requires a
pain assessment and a change in medication or increase in the dose or frequency.
• When criteria include the verbiage “sustained,” more than one isolated reading is required.
• “Functional impairment" is a condition that results in limitations impacting Activities of Daily
Living (ADL).
o This criterion refers to functional impairment that developed during the current
hospitalization.
o This may NOT be used for an inpatient rehab evaluation.
• “Inadequate oral intake” refers to the inability to maintain hydration.
o Inability to tolerate PO, meaning persistent nausea after more than one dose of antiemetic.
o If a patient’s condition has stabilized and there is no clinical indication of “inability to
tolerate” oral intake, application of this criterion would not be appropriate.
o If patient is tolerating solid food, the 4-2-1 formula as described in McKesson’s note for
maintenance fluids does NOT apply.
• When the criteria states “Recently performed,” please read McKesson’s accompanying
criteria note.
• Temperature measurements monitored any route other than rectal should be applied in the
criteria as PO. To apply rectal temperature monitoring, subtract one degree to calculate oral
equivalent. (Example: 100.6 PR=99.6 PO.)
• “Hospital acquired” inpatient criteria must be met prior to using this point. This point is not to
be used following observation days.
• To meet the change in medication or dose criteria point, a change must be made in the
medication or the dose or frequency of the medication. It cannot be used when the route of
administration is changed or a medication is stopped, held or discontinued. For example,
changing the route of furosemide from IV to PO, would NOT meet this criteria point.
Observation Guidelines
Observation status is synonymous with outpatient level of care. The observation time frame is provided
as an opportunity to observe changes in a patient’s clinical condition to determine the need for admission
or transition.
• The observation time frame allows two overnight hospital stays to complete testing, evaluation,
treatment and procedures not appropriate for the inpatient setting. An additional overnight is
provided for patients who begin care after 6 p.m., except Federal Employee Program (FEP)
contracts (FEP/“R” prefix).
• Physician order is not required to apply observation criteria for traditional Blue Cross members.
• Blue Advantage requires a physician order for observation.
• Web portal entry is not required for observation.
• Patients who remain hospitalized beyond the observation time frame must transition into
inpatient status and must meet Episode Day 1 criteria. If admission criteria are not met,
physician referral is required.
• Web portal entry is required on day three when a patient transitions to inpatient status.
• Observation for Federal Employee Program is limited to 48 hours (see FEP section for
additional information).
2015 CURP Facility Resource Manual Page 13Observation Frequently Asked Questions
Question: What if the physician ordered inpatient, but the patient only meets observation criteria?
Answer: Follow in observation, monitoring for changes in the patient’s clinical status. Blue Cross does
not require a physician order to use observation criteria, except for Blue Advantage.
Question: What if a surgery could be inpatient or outpatient?
Answer: Patients may be classified based on physician/facility decision. Please consider patient copays
and deductibles based on individual contracts.
Question: When is a preoperative day considered observation?
Answer: Observation status is not appropriate for routine, elective preoperative days, with certain
exceptions as noted in the Preoperative Day section of this document.
Question: What if observation criteria are not met?
Answer: Observation criteria are not intended to provide guidance for every potential clinical situation.
Even though specific criteria may not address the clinical picture under review, observation can be
applied for the first two days (three days if admission after 6 p.m.). Physician referrals are not required
for observation, unless the patient has Blue Advantage. Reviewers should follow and monitor
observation status patients to determine the need for inpatient admission.
Question: May I use observation criteria for retro reviews or after discharge?
Answer: Yes. Retrospective review is conducted as if it were concurrent, applying the same rules and
guidelines.
Question: What if I have billing questions for observation?
Answer: Contact your Provider Network Services Representative.
Blue Advantage
Blue Advantage is a Blue Cross product option for Medicare-eligible members. Facility reimbursement
may be based on the Diagnoses Related Group (DRG) system per Medicare guidelines or per diem
contract. Blue Advantage contracts are identified by the alpha prefix “MBG.”
Observation Status:
• Physician order is required to file an observation claim.
• Observation stays do not require Web portal entry.
• If status is changed from inpatient to observation, the member should be notified in writing, similar
to a Medicare recipient. Issue Blue Advantage members the same letter/information used for
Medicare members. It is recommended, but not required, that the member sign to acknowledge
receiving the letter. The facility may leave the notice in the member’s medical record. According to
Centers for Medicare and Medicaid Services (CMS) guidelines, the letter must be given to the
member prior to discharge. If the member has already been discharged, the member does not need
the letter and the facility may only bill ancillary charges.
Admission Status:
• Patients must meet inpatient admission criteria and have an inpatient order.
• Use the date of the transition to inpatient as the admission date in the Web portal. Observation
days are included in the inpatient claim but are not included in the inpatient day count. Blue
Advantage reimburses DRG payment for medical admissions.
• All inpatient admissions, including surgical admissions, must be reviewed applying InterQual
Criteria, and entered into the Web portal.
2015 CURP Facility Resource Manual Page 14• To determine inpatient versus outpatient status for surgical admissions, refer to the following
documents, in order:
1. Centers for Medicare and Medicaid Services (CMS) Inpatient Only list
2. McKesson’s “Guidelines for Surgery and Procedures in the Inpatient Setting,” which
may be accessed through the Web portal
3. Blue Cross’ Procedural Length of Stay List
Continued Stay Review:
• Continued stay review is not required on Blue Advantage medical/surgical patients.
• Follow and monitor patient care and progress to ensure timely, appropriate care and transition
arrangements.
Transfers:
• When patients are transferred between facilities from inpatient status, the receiving facility must
enter one continued stay review for the corresponding episode day in the Web portal, if criteria
were met at the transferring facility.
• If criteria were not met at the transferring facility, or there is no documentation to confirm
criteria met, perform an Episode Day 1 review.
• When patients are transferred from the emergency room, the receiving facility must enter an
Episode Day 1 review.
Member Management (Case Management):
• Member Management referrals are not required for Blue Advantage members. However,
Member Management services are available when requested by a member.
Peer Clinical Reviewer (PCR) Referral:
• Admissions which do not meet criteria must be referred to the Blue Advantage Care Coordinator
via fax.
• If a non-certification letter is appropriate, it will be provided to the facility by the Blue
Advantage Care Coordinator.
• When entering referrals in the Web portal, select, “Pended per group instruction.”
Federal Employee Program (FEP)
Federal Employee Program (FEP) members are employees of the federal government, designated by the
“R” contract prefix. There are two classifications of FEP members with specific review guidelines:
• Federal Employee Program, retired, >65 years of age, with no Medicare Part A: Only
admission review with Web portal entry is required. PCR referral is required if InterQual
Criteria are not met on admission review.
• Federal Employee Program, not retired: Both admission review and continued stay review
are required, with Web portal entry of all days. PCR referral is required for all days not meeting
InterQual Criteria.
Observation Status:
• Observation is limited to an actual 48-hour period that starts when care is first received.
• Late admission does not provide an additional overnight.
• When patient status changes from inpatient to observation, an explanatory letter must be
provided to the patient by the facility. Change of classification notice may be forwarded to the
member’s home if they have already been discharged.
2015 CURP Facility Resource Manual Page 15• Outpatient claims billed individually or cumulatively with observation hours greater than 48 will
stop for review.
• Review criteria closely to determine if the patient meets inpatient criteria on day one or two.
• If the patient will remain in observation, the care should be expedited within 48 hours.
• In the rare incidence that observation care should require more than 48 hours, a medical
necessity determination is required. Contact a Clinical Auditor for a fax cover sheet. (This
includes patients with Medicare Part A only when billing Blue Cross for observation care.)
Member Management (Case Management):
• Federal Employee Program members must be referred to Member Management via the Web
portal by hospital day five.
• Behavioral health admissions must be referred on admission to New Directions Behavioral Health.
• Members admitted with case management needs may be referred on admission or at any time
needs are identified.
Reconsideration:
• Federal Employee Program members have the right to appeal non-certified hospital days via the
reconsideration process.
• See appeal process for details.
Peer Clinical Reviewer (PCR) Physician Referral Process
Blue Cross contracts with physicians who support the CURP referral, reconsideration and appeal
functions. When members no longer meet criteria, there are quality issues, delays in service or
preoperative days, cases are referred to physician reviewers, who apply medical knowledge and
expertise to make clinically relevant determinations. Medical necessity determinations by physician
reviewers override criteria. For Blue Advantage members, refer to the section entitled “Blue
Advantage.”
Facility referrals are requested via the Web portal by:
• Selecting “Refer to Medical PCR.”
• Referrals will be processed when pertinent clinical information that supports the medical
necessity of acute inpatient admission and/or continued stay is received.
• Fax coversheets may be obtained from Blue Cross Clinical Auditors.
• Examples of supporting documentation may include:
o History and physical
o Progress notes
o Physician orders
o Medication administration records
o Operative notes
o Graphic sheets
o Current labs
o Any diagnostic results pertinent to review
• Blue Cross will provide a response within three business days on concurrent referrals and 30
business days on retrospective referrals.
Non-Certification:
• When the PCR issues a non-certification decision, the appropriate notice is provided by
Blue Cross via fax to be delivered to the member or the member’s representative.
2015 CURP Facility Resource Manual Page 16• The facility reviewer will deliver the notice to the member or the member’s representative,
obtain a signature, and then return a copy of the signed notice within 24 hours to Blue Cross
via fax at 205-733-7287.
• If the member or the member’s representative declines to sign the notice, the facility
reviewer should document and fax the notice to Blue Cross. A witness signature is
required.
• After the issuance of a notice of non-certification for medical necessity, the member will
become financially responsible at midnight, if not discharged.
• If a non-certification determination is issued, a peer-to-peer conversation may be requested per
guidelines, appeal rights apply as well.
• The member’s condition should continue to be monitored. Subsequent reviews may be entered
into the Web portal using the pended status; however, referral to PCR is not required.
• If the patient’s clinical condition changes, you must contact a Clinical Auditor to discuss the
specific case before applying criteria. You will be instructed when criteria application is
appropriate and how to proceed since each individual case is different. Without Clinical
Auditor approval, the date in question is subject to audit and is considered non-covered,
because the physician determined that an acute level of care is no longer appropriate.
• If the patient’s clinical condition has significantly changed and subsequent PCR is indicated,
contact your Clinical Auditor to discuss the specific case. If additional information indicates a
review is warranted, you will be instructed by the Clinical Auditor on how to proceed.
Without Clinical Auditor approval, the PCR request will not be processed. If a non-covered
determination was related to a preoperative day or delay in service, then routine criteria
application process should be followed.
• Non-covered determinations should be communicated by the hospital utilization reviewer to the
appropriate billing staff to ensure correct claim filing.
• NOTE: Due to the hold harmless clause in the contract between Blue Cross and Blue Shield
of Alabama and CURP hospitals, patients cannot be billed for charges retrospectively non-
covered.
Appeal Process
Peer-to-Peer Communication (Reconsideration):
• After issuance of a non-certification letter, physicians/physician extenders may request a
telephone peer-to-peer conversation.
• The appropriate telephone number is provided in the non-certification letter.
• This option is available within ten business days of receipt of the non-certification determination
on concurrent reviews.
• After ten days, a standard appeal option is available.
Appeal of Non-Certification Process:
Blue Cross provides two appeal options, expedited or standard appeal, for hospitalized members who
receive letters of non-certification. Providers may only select one option. Additional member appeal
options are included in all non-certification letters.
Expedited Appeal:
• Request should be for an additional review of a non-certification determination of ongoing or
imminent services
• Occurs while patient is hospitalized, and may be requested within 72 hours of receipt of the non-
certification notice
• May be requested by the patient, family member/significant other or physician
2015 CURP Facility Resource Manual Page 17• Review will be conducted by a PCR who was not involved in the original non-certification
decision
• Determination will occur within 72 hours of receipt of faxed clinical information
• Notify the Appeals Department at the number on the fax coversheet, and immediately fax
clinical information to the same fax number as the original referral, clearly identifying the
request as an expedited appeal by checking the appropriate box
• If the non-certification decision is upheld Members choosing to remain hospitalized will
become financially responsible beginning after midnight of the date of the original non-
certification letter.
Standard Appeal:
• Formal telephone or written request must be received to initiate a review on a non-certification
determination of an admission, extended stay or other healthcare service
• Must be received within 180 days of the date of the non-certification letter
• May be requested by the facility, provider of services, physician, patient or family
member/significant other
• Review will be conducted by a PCR who was not involved in the original non-certification
decision
• A determination will be forwarded to the requestor within 30 days of receipt of all clinical
information necessary to make a decision
• Written requests for standard appeals should be addressed to:
Blue Cross and Blue Shield of Alabama
Attention: CURP/Standard Appeal/Health Management
P.O. Box 360167
Birmingham, Alabama 35236-0167
• In addition to appeal options provided by Blue Cross, members may have additional appeal
options (e.g., Department of Labor (DOL)/ Employee Retirement Income Security Act (ERISA),
and/or special groups)
• Refer to the telephone number on the back of the members’ Blue Cross ID card to identify
group-specific appeal information
• Members may also contact Customer Service for this information or to request a DOL/ERISA
appeal
Blue Advantage Appeals:
• Hospital days that do not meet InterQual Criteria are referred to the Blue Advantage Care
Coordinator for review and determination
• Non-certification determinations issued by the Peer Clinical Reviewer will be faxed to the
facility for delivery to the member or the member’s representative
• Per CMS guidelines, contract providers do not have appeal rights
• Peer-to-peer reconsideration is provided within ten business days of the non-certification
notification
• Appeal options are available for members and are included in the non-certification letter
• If an appeal request pertains to a continued stay and the member has not been discharged,
the physician may request an appeal on the member’s behalf
• If member has been discharged, appeal options are no longer available. For additional information
call 1-888-341-5030
2015 CURP Facility Resource Manual Page 18Federal Employee Program (FEP) Reconsideration:
• Is defined and governed by federal regulations, and is available only to the member or the
member’s representative
• As a courtesy to our providers, Blue Cross will provide one review of a non-certification
determination upon request
• Reconsideration request must be received within six months of the non-certification notification
CURP Resources
Local (Organizational) Policies/McKesson’s Informational Notes
Local policies and/or criteria clarifications are embedded within the Blue Cross Web-based version of
McKesson’s InterQual Criteria. These organizational policies are indicated in the Web portal by a
yellow “P” beside the applicable criteria.
Medical/Surgical local policies/criteria clarification
McKesson’s Informational Notes and Blue Cross’ Local Policies are indicated in the InterQual review
by the following symbols:
The pale yellow “N” represents McKesson’s Informational Notes which explain and/or give
clarity to the criteria.
The bright yellow “P” represents Blue Cross organizational policies which differ from or clarify
McKesson’s guidelines. Read them (if applicable) in their entirety for clarification.
CURP Publications
CURP publications are accessed from the Case List page. Click on CURP Publication link to be viewed.
• CURPFacts
• CURP Flash
• CURP Resource Manual
CURPFacts is a quarterly publication that provides CURP audit summary information as well as helpful
tips for InterQual application.
A CURP Flash is used periodically to inform CURP facilities of any important group updates or review
process changes. Notices are sent via email when new information is available. Contact assigned
Clinical Auditor to receive these important publications.
InterQual Resources
There are helpful resources in the Web portal inside the InterQual review such as Clinical Revisions,
Abbreviations and Symbols and Drug List.
• Click on “Help” in the upper right-hand corner and a drop-down menu will open.
• Click on the resource to be viewed.
2015 CURP Facility Resource Manual Page 19Terminology/Definitions Crisis stabilization: Emergency or urgent treatment rendered to rescue a patient from an unstable/unsafe clinical/emotional state. Transfer to an appropriate LOC or alternate facility usually follows crisis stabilization. Delay in Service: Inefficient delivery of healthcare treatment resulting in unnecessary inpatient days (e.g., surgical scheduling delays due to weekends, holidays or conflicts). Failed Outpatient Treatment: Documentation must be specific, reflecting type of treatment rendered, duration of treatment and nature of the member’s response to treatment. Onset of Symptoms: Time requirements within InterQual Criteria clarify variable time frames acceptable for onset of symptoms. Onset of symptoms for chronic illness refers to an exacerbation of illness within the specific time frame. Forms and Web Links Member Management Referral Criteria List When a referral to Member Management is submitted via the web portal, supporting clinical documentation should be faxed as a follow-up to the referral utilizing the fax coversheet in the link below. Member Management/Disease Management Referral Form Medical/Surgical local policies/criteria clarification Peer Clinical Reviewer (PCR) Referrals (Medical/Surgical/FEP Observation) • Contact your Clinical Auditor for fax coversheets The Procedural Length of Stay List (CPT Code Order or Body System Order) Possibly Non-Covered Procedure List 2015 CURP Facility Resource Manual Page 20
You can also read
