Hospital Observation Admission
Effective January 1, 2016
Facility must send request for observation admission to Security Health Plan via fax within 48 hours of member being admitted to Observation status in the facility.
If Security Health Plan’s review indicates that the member meets medical necessity for observation, the facility will receive approval for two observation days.If additional observation days are required, facility must submit daily clinical documentation which Security Health Plan will review and render a daily determination within 24 hours or next business day after receipt of clinical information.
Claims submitted need to match the appropriate dates and level of care indicated for the authorization number(s) granted. Example: On day one you receive authorization for observation. On day two the patient’s level of care meets inpatient status. You must submit a claim for observation status for day one, and a claim for inpatient status on day two.
As a reminder, there are unforeseen circumstances set forth by CMS relating to inpatient-only admissions. These unforeseen circumstances may result in a shorter stay than the physician’s expectation:
- Departure against medical advice (AMA)
- Unforeseen recovery
- Election of Hospice
Such claims may be considered appropriate for hospital inpatient payment/billing. Please fax clinical information to support claims. The physician’s expectations and any unforeseen interruptions in care must be documented in the medical record.
Once approval for inpatient status has been received:
DRG Facilities: No further reviews required.
Critical Access/Non DRG facilities: Follow your current process and provide Security Health Plan updates if the member requires additional days past the certified days approved.NOTE:
- If the provider fails to provide the needed clinical information within 24 hours of the admission (Observation and/or Inpatient), Security Health Plan will deny for provider contract requirement. Each day will be denied to the provider until Security Health Plan receives required clinical information. Provider cannot bill the member for these denied charges.
- If ultimately it is determined that the patient did not meet medical necessity for the admission, payment for services will be denied to the Provider. Provider cannot bill the member for these denied charges. Provider may appeal through Security Health Plan’s Appeal Process.