Provider Portal - Create Emergent Inpatient Admission Notifications

How to complete the provider portal screens

An emergent inpatient admission notification consists of two parts.

Part One

Identify Member
Requesting Provider, i.e., admitting facility
Admitting Provider
Diagnosis Code(s)
Service Details
Created By
Review Details

Saving Drafts: After the first set of information is entered and reviewed, any authorized user may continue directly to Part Two or they can save a draft for 120 hours. Once a draft is saved, the original user or another associated with the notification, can find the draft, address the MCG/Clinical Guidelines, and attach supporting documentation needed for the concurrent review.

Part Two

MCG/Clinical Guidelines Attach Supporting Documentation

NOTE: The portal will not allow a notification to be submitted until the expected MCG/Clinical Guideline(s) is addressed and supporting documentation attached.

Emergent Inpatient Admission Notification Transaction

When a member is admitted to an inpatient hospital from an emergency room, hospitals are required to notify the member’s Managing Entity. For notification requirements see the EmblemHealth Provider Manual Utilization Management chapter and ConnectiCare’s Coverage Guidelines. While emergent inpatient admissions do not require preauthorization, the inpatient stay is subject to concurrent review.

The steps below show how to complete the provider portal screens needed to notify EmblemHealth and ConnectiCare of the admission and to provide clinical information to start the concurrent review process. The portals for EmblemHealth and ConnectiCare have the same functionality and can be used for both company’s members.

Once a notification has been submitted, you will be able to request modifications to certain data elements through the provider portal too.

STOP: If the member’s Managing Entity is not EmblemHealth you must notify the member’s assigned organization directly.

NOTE: On each screen, required data elements will have an asterisk “*” next to the field name.

Part One: Starting A New Emergent Inpatient Admission Notification

PART 1

There are two ways to start a notice:

Use the Take action box on the Provider Portal Home page.
From any screen, use the top Preauthorization menu to select Create Emergent Inpatient Admission.

TIP: Click More to view Create Emergent Inpatient Admission, if it is not on the menu tab.

Identify Member

STOP: If EmblemHealth is not the member’s Managing Entity, you must notify the Managing Entity directly. They are responsible for conducting concurrent review for the member’s inpatient stay. See detailed instructions for finding the member.

TIP: From the search results table, select the row with an Active Status and Medical Coverage Type.

On this screen the user will also be prompted to check off two items to acknowledge:

1. The notification will not be considered submitted until all required clinical information is provided and the Submit Notification button at the end of the transaction is clicked to begin the concurrent review of the inpatient stay.

2. That by choosing to save a draft, one will be available for 120 hours. During this time, authorized users will be able to see, contribute to, and submit the preauthorization request.

Requesting Provider - Inpatient Facility

On this screen you will search for and select the inpatient facility where the member has been admitted. You will see a pop-up alert if an out-of-network provider is selected. See detailed instructions for finding the facility.

TIP: We recommend searching by NPI.

Admitting Provider - Doctor or Practitioner

The Admitting Provider is the doctor or practitioner who is responsible for the member’s care. See detailed instructions for finding the admitting provider.

Diagnosis Codes

On this screen you will enter the primary and secondary Diagnosis Codes. See detailed instructions for finding Diagnosis Codes.

The Primary diagnosis code is mandatory while secondary diagnosis codes are optional. Use the Secondary Diagnosis Codes section to search for and add up to 11 secondary diagnoses. Between diagnoses, click Add to enter the next code.

NOTE: The diagnosis codes entered here will determine which MCG/Clinical Guideline(s) the portal will expect to be addressed in Part Two.

TIP: If the notice is saved as a draft and the diagnosis changes before the clinical information is entered, we recommend restarting with a new notice so the portal can prompt you for the applicable clinical criteria.

Service Details

The fields Place of Service and Type of Care are prepopulated.

Pick the Service Type from the drop-down menu choices:

Medical Care
Surgical
Newborn Nursery (Well Baby)
Maternity/Obstetrics
Neonatal Intensive Care

Enter the Admission Date and Time.

Check the box if the member has already been discharged and enter the date, time, and select the discharge disposition from the drop-down menu.

Request Contact(s)

Enter the information for the person EmblemHealth or ConnectiCare should call if we need more information. You may also be prompted with an option to have the identified Contact receive notification of the determination by email.

If the person who starts the notice does not submit it, the identified Contact will receive an email letting them know a draft is active and needs attention. The Contact will also receive an email if the draft is not completed and expires.

Review Details

You can review the details of all the sections you have completed.

Click Edit in the applicable section if you need to change any information.

WARNING! Once you complete this screen and click Next, you will not be able to make additional edits to the information entered before the notice is submitted.

Diagnosis Code Accuracy: If the notice is saved as a draft and the diagnosis changes before the clinical information is entered, we recommend restarting with a new notice so the portal can prompt you for the applicable clinical criteria.

You will be given the option to continue or save a draft for 120 hours.

Intermission: Saving and Finding Drafts

Save Draft

You will be given the option of continuing or saving a draft for 120 hours.

Reminder emails: If you save a draft, the identified Contact will be sent an email reminder before the draft expires. If no action is taken after the reminder, another email will be sent notifying the Contact that the draft expired.

Finding Incomplete Notices

At the end of Part One, on the Review Details screen, you can choose to continue or exit and save a draft of the notice for 120 hours.

Anyone associated with the notice can find a copy of the draft, address the MCG/Clinical Guidelines, attach supporting documentation, and submit the notice.

TIP: If you save a draft and expect someone else to enter the clinical information, make sure they know you have started the notice, share the Draft Number and how much time they have to finish and submit it. If you enter their information as the identified Contact, we will send them an email reminder before the draft expires. If no action is taken after the reminder, we will send another email letting them know the draft expired.

Navigating to Drafts

There are three ways to get to the screen that lists the incomplete and expired draft requests created in the last 30 days:

STEP 1 AND 2

1. On the Provider Portal Home page use the Take action box to Finish Incomplete Preauthorization Requests and Notifications.

2. From any screen, use Preauthorization from the top menu to select Incomplete Requests & Notifications.

STEP 3

3. On the Preauthorization Requests page, there is a link to the list.

Incomplete Emergent Inpatient Admission Notifications

On the Incomplete Preauthorization Requests and Emergent Inpatient Admission Notifications page, you will be able to locate both the active and expired drafts submitted in the last 30 days.

STEPS

Enter the requesting or servicing provider’s/facility’s NPI if no results appear.
Click the Draft Number to open an active draft.
Click a column heading to sort the table, e.g., click Draft Retained Until to see active vs. expired drafts.
Use the Filter By box to search by any of the data shown in the table.

To find a draft for a specific member, enter the Member ID or Member Name in the Filter By box, or sort on the Member ID or Member Name column and scroll through the table.

Expired Drafts

If the draft is expired, the Draft Number will no longer be a functioning link and the Draft Retained Until column will show a date/time that is more than 120 hours past the Draft Initiated date/time.

If the member was admitted to the hospital from the emergency room, a new notification should be submitted even if the member has already been discharged.

Association With Notice

Anyone who is associated with the notice will be able to find a copy of the draft to complete the clinical information, attach supporting documentation, and submit the notice.

To be associated with the notice, you must have the Administrator/Office Manager or Clinical Staff role and be linked to the tax ID for the:

Requesting Provider
Requesting Facility
Servicing Provider
Servicing Facility
Discharging Facility

Part Two: Add Clinical Information For Concurrent Review

Once Part One screens are completed, clinical information will be required for concurrent review. The provision of clinical information has two parts:

MCG/Clinical Guidelines
Attach Files

If the clinical criteria are met, approval for the initial concurrent review may be issued at the end of the transaction. Otherwise, the notice will pend for further review. In either case, for the emergent inpatient admission notification to be considered complete and submitted, the Submit Request button on the MCG screen must be clicked.

TIP: Once the request is submitted, it will no longer appear on the Incomplete Drafts list.

NOTE: The Authorization field on the MCG screen will display a number. This is not an approval number. It is the Draft Number for the notice.

MCG/Clinical Guidelines Required

The diagnosis code entered determines which MCG/Clinical Guidelines will be required. If guidelines are required, you will see orange Document Clinical button(s) you will need to address by checking off the clinical criteria that apply to the notification. You must also click the blue Attach File button to share supporting documentation such as medical records and test results.

WARNING! The Submit Request button will remain inactive until each Document Clinical button is addressed and expected documentation attached. Once the clinical information is entered and all documents are attached, you must click the Submit Request button to finish the transaction.

Document Clinical - Example

Once you click the Document Clinical button, you will be shown a list of potential clinical guidelines that may apply.

Example: Diagnosis M54 Dorsalgia where the Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy guideline applies.

To pick the guideline for the diagnosis M54 Dorsalgia, click add in the Action column for the Guideline Title Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy.

Once a guideline is selected, you will be shown criteria that could apply.

1. Click all boxes that apply to your patient.

2. If you see this Add Notes symbol, you can click it to see a pop-up screen where you can add notes up to 250 characters in length.

Once appropriate criteria have been selected and notes entered, click the Save button.

Select Guideline

Click Add To Select Whichever Guideline You Want

Select Applicable Criteria

Click The Boxes That Apply To The Patient's Condition

Attach File - Add Supporting Documents

You must use the blue Attach File button to upload medical records and other supporting documentation. The Submit Request button will not activate until documentation is attached.

Step 1: Choose file.
Step 2: Upload file.
Step 3: Close pop-up.

Each file may be up to 25 MB in size. You are able to attach the following file types:

Microsoft Word documents (.doc and .docx).
Microsoft Excel files (.xls, .xlsx).
Image files (jpg, .tiff, .gif, and .bmp).
PDF files.

The File Description is optional. If you do not enter a description, the file name will used.

When you are done attaching documents and all of the clinical guidelines have been addressed, click the Submit Request button.

No Clinical Information Required

If no additional information is needed, you will see a screen indicating “MCG Guideline Documentation Not Required.” The Submit Request button will be inactive until supporting documentation is attached.

NOTE: If the Document Clinical button displays, but on the next screen you do not see an applicable guideline or are unsure of which guideline to choose, click add in the Action column for “No Guideline Applies”. This will display a notes screen. Describe the reason why the listed guidelines are not appropriate and why the member needs the services.

Using The Back/Previous Button

If you do not have full clinical information, you may use the Back button to save the information entered. You will still have the remainder of the 120 hours to finish adding the clinical information and submit the request.

Confirmation

1. The Concurrent Review Status screen displays. In some cases, the information submitted will be sufficient to meet the initial concurrent review. Additional information may be needed for extended stay requests and discharge planning. Other cases may pend for concurrent review.

2. To exit, click Done.

Take advantage of the Concurrent Review Status Report to manage your inpatient cases.

Emergent Inpatient Admission Notifications

How to complete the provider portal screens

Emergent Inpatient Admission Notification Transaction

Part One: Starting A New Emergent Inpatient Admission Notification

Identify Member

Requesting Provider - Inpatient Facility

Admitting Provider - Doctor or Practitioner

Diagnosis Codes

Service Details

Request Contact(s)

Review Details

Intermission: Saving and Finding Drafts

Save Draft

Finding Incomplete Notices

Incomplete Emergent Inpatient Admission Notifications

Expired Drafts

Association With Notice

Part Two: Add Clinical Information For Concurrent Review

MCG/Clinical Guidelines Required

Document Clinical - Example

Attach File - Add Supporting Documents

No Clinical Information Required

Using The Back/Previous Button

Confirmation

Provider

Access the ConnectiCare Portal

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Any information provided on this website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.