Missing Notification/Late Notification Process Reminder
Effective September 1, 2019, failure to obtain prior authorization or to notify Healthy Blue within the established guidelines as outlined below will result in an administrative denial. For our participating providers, this is a contractual obligation and has been in effect since the execution of your contract.
What this means to me
Beginning on September 1, 2019, if you do not obtain the required prior authorization or provide notification within the specified time frame, your claim will be denied due to failure to notify Healthy Blue. You will not receive payment for the service(s).
If you do not notify us within the required time frame, you may file an appeal. As part of the appeal, you must demonstrate that you notified Healthy Blue or attempted to notify Healthy Blue and that the service is medically necessary.
What is the impact of this change?
Healthy Blue must be notified of all admissions or transfers within one business day of admission. Ideally, notification occurs on the day of admission; however, the provider has one business day to notify without penalty. A business day is considered Monday through Friday, not including weekends and federal holidays. The following have been impacted as noted:
- All post-stabilization admissions,* including transfers within one business day of admission — the following clinical scenarios are excluded:
- Admission to neonatal intensive care unit (NICU) level III
- Admission to intensive care unit (ICU)
- Direct admission to operating room (OR)/recovery room
- Direct admission to telemetry floor
- Involuntary behavioral health admissions
- Obstetric admissions — antepartum/postpartum admission not resulting in a delivery
* Note: Admission to a general floor/ward is considered in scope for our notification requirements. Failure to notify us within one business day of admission to the general ward or NICU level I or II is considered failure to notify; an administrative denial applies. Once the member has left NICU level III, ICU, OR/recovery or telemetry, the requirement for notification within one business day applies.
Additionally, please note that we require prior authorization for the following:
- Nonemergent inpatient transfers between acute facilities
- Elective inpatient admissions
- Rehabilitation facility admissions
- Long-term acute care admissions
- Skilled nursing facility admissions
- Behavioral health — levels of care as outlined in the provider manual/prior authorization documents
- Out-of-area and out-of-network services
- Outpatient services
- Outpatient DME purchases and rentals
Members cannot be balance billed for any denial. To obtain prior authorization or to verify member eligibility, benefits or account information, call the number listed on the member’s plan membership card.
Please use one of the following methods to request prior authorization:
- Phone: 866-902-1689, option 3
- Fax: 800-823-5520
For detailed prior authorization requirements, visit www.HealthyBlueSC.com and select Providers.
What if I need assistance?
If you have questions about this communication or need assistance with any other item, call the Customer Care Center at 866-757-8286.