Commercial - Medical Management Programs
ConnectiCare approves a length of stay based upon medical
necessity on a concurrent review basis. Inpatient care and home care services
are subject to concurrent review, which is conducted by a ConnectiCare case
manager or designee over the telephone or through direct medical chart review.
ConnectiCare uses nationally recognized medical necessity criteria for medical
surgical/acute care admissions, skilled nursing/sub-acute admissions, home
health care services, and observation level of care.
If you have any questions or would like a copy of the criteria
specific to a member’s condition, please contact the case manager with whom you
are working, or call 1-800-562-6833.
Although concurrent review activity involves the facility or
agency utilization review departments, physicians are frequently contacted for
information and assistance in developing a discharge plan that facilitates the
delivery of services in the most appropriate setting. The attending physician is
contacted for more information when it appears that the member’s condition does
not meet continued stay criteria. If the intensity of services or severity of
illness of the member does not support a continued stay at the current level of
care, the applicable physician organization’s medical director or a ConnectiCare
medical director will review the case. If the authorized length of stay has
expired before a continuance is approved, the member may not be held responsible
for the fees associated with such services, unless the member was otherwise
notified in writing by ConnectiCare in advance.
Note: Practitioners and other providers are expected to comply
with inpatient reviews upon request, even when ConnectiCare is the secondary
carrier for the member.
Per Federal Department of Labor and NCQA timeliness standards,
ConnectiCare will issue a decision for a concurrent review within twenty-four
(24) hours of the request. If ConnectiCare makes an attempt to obtain the needed
clinical information in this twenty-four (24) hour period and the information is
not provided, ConnectiCare is still required to issue a determination. In this
case, ConnectiCare will issue a determination based on the information already
In addition, circumstances may occur during a hospital/facility
admission in which the patient’s care or treatment is delayed by scheduling
problems, delays in getting needed evaluations or consultations, delays in
discharge planning, the unavailability of hospital/facility services over the
weekend or on holidays, or other administrative delays. These cases will also be
reviewed by the applicable physician organization medical director or a
ConnectiCare medical director for determination of authorization of payment.
If the delay in discharge results from a
facility’s delay in providing needed services, attending physicians will be
compensated for their services during this time. However, if the delay in
discharge is due to a decision or lack of action by the attending physician,
that physician will not be compensated for days not
What happens next?
• ConnectiCare’s medical director will review the
request for continued stay and make the determination.
• If the decision results in extending coverage, the notification
will include the number of extended services approved, the new total of approved
services, the date of onset of the services, and the next review date.
• If health services can be provided in more than one medically
appropriate setting, it is within ConnectiCare's discretion to choose the
setting for the provision of those services. In addition, the services must be
provided in that setting in order for the member to be eligible for benefit
• If the medical director determines that continued payment for the
facility stay cannot be authorized, the attending physician will be notified by
phone or fax and will also receive written confirmation. If upon review of
clinical documentation the medical director does not approve the day(s), you may
utilize their consideration process and/or appeal the decision. See
"Reconsideration Process" and/or "Provider Appeals" for additional information.
• The written notification will include: the reason for the
determination and clinical rationale, if any; instructions on how to initiate an
appeal of the decision; general information on external appeal rights, if
applicable, including how to initiate an external appeal; notice of the
availability of clinical review criteria referenced in the decision, and the
name and phone number of the physician reviewer who made the