Commercial - Medical Management Programs |
Pre-service Review: Inpatient Admissions
|
Physicians must notify ConnectiCare in advance of elective admissions
so that concurrent review can begin in a timely manner.
|
The following information pertains to admitting members to both participating
(in-plan) and non-participating (out-of-plan) inpatient facilities.
If admitting to a PARTICIPATING (in-plan) Facility:
• The physician must obtain pre-authorization of all elective inpatient
admissions at least five (5) business days in advance. (Pre-authorization is
required even when ConnectiCare is secondary payer.)
• All elective pre-authorizations must be requested during normal business
hours.
• The hospital should verify that the pre-authorization has been obtained by
calling Provider Services at 1-800-828-3407.
• Physicians, hospitals, or other Health Delivery Organizations (HDOs) should
notify ConnectiCare within twenty-four (24) hours for any emergency or urgent
admission. Call us at 1-800-508-6157.
Note: Failure to obtain prior authorization for elective
admissions or elective procedures may result in a denial of payment to the
participating practitioner and/or provider. The member may not be billed for a
claim denied for failure to obtain prior authorization.
If admitting to a NON-PARTICIPATING (out-of-plan) Facility:
• Elective admissions to non-participating
hospitals are not covered, unless specifically authorized in writing, in advance
by ConnectiCare, or, if the member has a Point-of-Service or PPO Plan. You must
submit your request for an out-of-plan authorization at least five (5) business
days in advance of the anticipated admission date.
• ConnectiCare will give authorization only for services that are
not available within ConnectiCare’s participating provider network, unless the
member has a Point-of-Service or PPO Plan.
Exception: If they choose, members with a Point-of-Service, PPO,
or FlexPOS benefit design may exercise their option to access out-of-plan
hospitals without pre-authorization. This subjects the member to both
out-of-network benefit levels and additional benefit reduction. In addition, the
member is responsible for obtaining any necessary pre-authorizations. Member ID
cards clearly identify the Point-of-Service product. Ask members to call Member
Services at (860) 674-5757 or 1-800-251-7722 if they have any questions about
their benefits.
Required Information for Elective Inpatient Pre-authorization
• Member’s name and date of birth
• Member’s address and telephone number
• Member ID number
• Scheduled admission date or estimated date of delivery if obstetrical patient
• Name of hospital/facility
• Admitting provider’s name and ConnectiCare provider ID number
• Primary and secondary diagnoses, using ICD-9 codes
• Reason for hospitalization, using CPT-4 codes, if applicable
Skilled Nursing Facility Admissions
If you admit a member to a skilled nursing facility (SNF) on a
weekend or holiday, ConnectiCare will automatically authorize payment from the
day of admission through the next business day. However, ConnectiCare will not
automatically pay for admission to a SNF for rehabilitation in the absence of a
hospitalization or acute episode of illness or injury. These admissions require
pre-authorization during regular business hours and are subject to medical
necessity review.
You must call ConnectiCare’s Notification Line at (860) 674-5870
or 1-800-508-6157 to advise us of the admission. This line is available
twenty-four (24) hours/day, seven (7) days/week. If you do not inform
ConnectiCare according to these guidelines, the SNF may not receive payment for
any additional days of the member’s stay.
In addition, ConnectiCare will deny admissions to a SNF that is
under Denial of Payment of New Admissions (DOPNA) status by CMS or the State of
Connecticut. If a member is already in a facility when it goes on a DOPNA status, then we
will offer the member the option to transfer to a different SNF.
Providers:
• Must obtain pre-authorization for admission to a SNF for rehabilitation in the absence of a hospitalization or acute episode of illness or injury. This admission is subject to medical necessity review.
• Do not have to obtain pre-authorization for land ambulance/medical transport from an in-network hospital to an in-network SNF.
What happens next?
• As appropriate, ConnectiCare’s medical director
may review the proposed admission and make the determination.
• If the admission meets accepted criteria for medical necessity and
place of service, and the request is approved, an authorization number is
assigned.
• If the admission does not meet established criteria, you may be
asked to advise ConnectiCare of additional indications in support
of the admission.
• When a request for authorization is denied, ConnectiCare will
notify the member and physician in writing, including: the reason for the
determination and clinical rationale, if any; instructions on how to initiate an
appeal of the decision; notice of the availability of clinical review criteria
referenced in the decision; general information on external appeal rights,
including how to initiate an external appeal, if applicable; notification of the
appeals process if the provider and/or member choose to appeal the decision, and
the name and phone number of the physician reviewer who made the decision. Refer
to the Appendices at the back of the Manual for detailed information regarding
appeals. Note: external appeal may only be available only after the internal
appeal process has been exhausted.
• 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 for benefit purposes. In addition,
the services must be provided in that setting in order for the member to be
eligible for benefit coverage.
• The hospital or other Health Delivery Organization (HDO) must
notify ConnectiCare to confirm that a patient who has been pre-authorized for an
elective inpatient stay has been admitted. Call 1-888-261-2273 to leave
applicable information.
• The hospital or other HDO must notify ConnectiCare in the event of
a member signing out against medical advice.
Note: Providers are expected to provide inpatient reviews upon
request, even when ConnectiCare is the secondary carrier for the member.
