This article is for primary care physicians, orthopedic surgeons, and hospitals caring for our members
As a reminder, Blue Cross uses InterQual®' criteria to review medical necessity for hip and knee total joint replacements for our commercial (HMO, PPO, Indemnity) members. This does not apply to our Medicare Advantage, Medex®'', or Federal Employee Program (FEP) members.
To determine the most suitable level of care, submitted documentation must support inpatient admission requests. We may redirect to the outpatient setting as appropriate.
We can lessen the impact and overutilization of inpatient care in overwhelmed hospitals, especially during the pandemic, by directing care to the most appropriate setting.
Please continue submitting authorization requests for total joint replacements via Authorization Manager.
Authorization Manager streamlines the process of submitting and viewing referral and authorization requests. With built-in InterQual criteria and an easy-to-use interface, this helpful tool simplifies and expedites the work you do.