Medicare - Medical Management Programs |
Pre-service Review: Inpatient Admissions
|
Physicians must obtain prior approval for elective admissions prior to admission, and the facility or physician must notify ConnectiCare of emergency admissions so 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 1-877-224-8230.
• Physicians, hospitals, or other Health Delivery Organizations (HDOs) should notify ConnectiCare within twenty-four (24) hours for any emergency or urgent admission 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. 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.
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. These admissions are subject to medical necessity review. Original Medicare's requirement that the SNF admission be preceded by a 3-day qualifying stay does not apply for ConnectiCare members.
You must call Utilization Management at 1-800-508-6157 to advise ConnectiCare 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?
• ConnectiCare’s medical director will review the proposed admission and make the determination.
• If the admission meets Medicare guidelines and the request is approved, an authorization number is assigned and the provider receives a phone call with the authorization number.
• If the admission does not meet Medicare guidelines, 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; notice of the availability of Medicare guidelines referenced in the decision; information about appeal rights, including how to initiate an 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.
• 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 1-800-508-6157 to leave applicable information.
• The hospital or other HDO must notify ConnectiCare in the event of a member signing out against medical advice.
|
ConnectiCare requires that certain services and medical procedures be reviewed for medical necessity prior to the delivery of those services if appropriate. Procedures are pre-authorized using Medicare guidelines. For a copy of these guidelines, contact the case manager with whom you are working, or call 1-800-508-6157.
|
Notice of Medicare Non-Coverage with Appeal Rights
Skilled Nursing Facilities: Once the last date of covered services is determined, ConnectiCare will fax you the Notice of Medicare Non-Coverage with Appeal Rights at least two days prior to the services not being covered. You are responsible for providing the Notice with Appeal Rights to the member (or legal representative) and obtaining a signature with the date signed. A copy of the signed and dated notice must be faxed to ConnectiCare at (860) 674–2831. If you are unable to deliver the notice at least two days prior to the last date of covered services – you must contact ConnectiCare at 1-800-451-7784.
Home Care Agencies and Comprehensive Outpatient Rehabilitation Facilities: The Notice of Medicare Non-Coverage with Appeal Rights must be provided to the member (or legal representative) at least two days prior to the discontinuation of services. If there is more than a two-day span between services, the notice should be issued the next to last time the services are provided. A copy of the signed and dated notice must be faxed to ConnectiCare at (860) 674–5893. If you are unable to provide the notice at least two days prior to the discontinuation of services – you must contact ConnectiCare at 1-800-451-778
