Name of Manual - Blue Cross and Blue Shield of Minnesota

Pre-certification and
Concurrent Review for
Inpatient/Residential
Mental Health and
Substance use
Disorder Services
Coding Policies and Guidelines (Behavioral Health)
To help assure that members receive the appropriate level of care
for mental health and substance use disorder treatment, Blue
Cross, as done with other medical/surgical services, require certain
pre-certification and concurrent review protocols for
inpatient/residential services.
This program will continue to expand and impacted providers will
receive additional information once these requirements are
expanded.
Pre-certification and concurrent review applies to health services
provided to members in fully insured and self-insured benefit
plans, including Minnesota Health Care Programs, with the
exception of Minnesota Senior Care Plus (MSC+), SecureBlue
(HMO SNP), Platinum Blue (Cost) and MedicareBlue PPO
(Regional PPO) members. Medicare supplement benefit plans are
also excluded from review. This also does not apply to court
ordered admissions to inpatient/residential treatment. Coverage for
court ordered mental health services is detailed in Minnesota
Statute 62Q.535.
Definitions
"Pre-certification" is defined as an advance review of a proposed
facility admission or certain services or procedures in order to
determine whether the proposed admission, services or procedures
meet the medical necessity criteria for payment and to ensure that
the subscriber receives the maximum benefits available under the
subscriber’s plan.
"Concurrent review" is defined as ongoing review during the
subscriber’s care to ensure that it meets established medical
criteria in a timely manner and certifies the necessity, the
appropriateness and quality of services during an inpatient
admission.
Pre-certification Requirements
Provider will obtain pre-certification from Blue Cross before
admitting a member. If admission is emergent or after business
hours, provider will obtain pre-certification within two (2)
business days after the admission.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12 11-55