Medicare - Medical Management Programs |
Concurrent Review
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 Medicare guidelines 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 guideline specific to a member’s condition, please contact the case manager with whom you are working, or call 1-800-508-6157.
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.
ConnectiCare will issue a decision in a timeframe consistent with federal regulation for a concurrent review. If ConnectiCare makes an attempt to obtain the needed clinical information in this timeframe 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 made available. An administrative denial may be issued if information was requested but not submitted within this twenty-four (24) hour period.
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 to the hospital/facility and physician.
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 authorized.
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 coverage.
• 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 the reconsideration process and/or appeal the decision. See "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; 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 decision.
