Pre-certification Notification and Concurrent Review Guide
Provider responsibilities include:
- Precertify all elective inpatient admissions/surgeries and outpatient procedures such as, but not limited to:
- Carpal tunnel, knee arthroscopy, back surgeries and hysterectomy with the diagnosis of fibroids
- Notify Security Health Plan at 1-800-548-1224 of all direct/urgent inpatient admissions.
- Provide the medical information necessary to evaluate inpatient admissions.
- Notify Security Health Plan with any of the following changes prior to services being provided:
- level of care
- procedural changes
- site of service
- date of service
- provider providing service
Hospital responsibilities include:
- Notify Security Health Plan at 1-800-548-1224 of all observation and acute inpatient admissions and provide clinical information within 24 hours of notification or the next business day.
- Provide timely concurrent review activities (telephonic and on-site) to prevent penalty for late notification. A timely review is defined as providing clinical information within 24 hours of the last covered day.
- Failure to provide this information means Security Health Plan will not be able to perform timely initial or concurrent review of the admission. Security Health Plan will therefore not reimburse the facility for covered services incurred prior to the performance of the initial or concurrent review of the admission. The facility shall not bill, charge, collect a deposit from, seek remuneration or compensation from the Security Health Plan member, or any person acting on the member’s behalf, for covered services incurred prior to the performance of the initial or concurrent review
Home health agency responsibilities include:
- Notify Security Health Plan within 48 hours or within 2 business days of rendering home health services.
Precertification of Hospital Admissions
Based on medical diagnosis or proposed surgery and medical information, Security Health Plan will:
- authorize coverage for a length of stay based on InterQual Level of Care Criteria and Truven, which are a minimum length of stay consistent with quality care – not an average or maximum. Actual length of coverage for a stay is based on medical necessity and intensity of service.
- notify the physician of concurrent review for those admissions with no specific length of stay.
- upon request, send a copy of the appropriate InterQual Level of Care Criteria, available by contacting the Security Health Plan utilization review coordinator.
- follow the admission with the hospital utilization review department if the member is not discharged within the precertified time frame. The admission will be reviewed for medical necessity and intensity of service.
- contact the provider for additional information if not available through the hospital utilization review department to determine if additional days will be covered or denied based on medical necessity for an acute care setting. Alternate settings and appropriate home health services will be explored for those who do not meet criteria for continued coverage of acute care.
The provider, not the member, is responsible to precertify an admission to the hospital for medical and/or surgical treatment.
FACILITIES TO DELIVER STANDARD DETERMINATION APPROVAL NOTICES
When a Security Health Plan (SHP) Commercial member is in a hospital (inpatient or observation status), the facility is required to provide notice of approvals and denials for services members request as part of the Standard Determination process. The process is outlined below to help your staff deliver the approvals and denials.
Notice of Approved Benefit Determination
An approved benefit determination notice is provided to the requesting facility.
- Notice includes a reference identifier and indicates the service to which the coverage has been applied.
- When notice is required by law or per account contract to be provided to the member, it may be provided verbally, via secure internet portal or in writing.
- The ordering and/or rendering provider/facility requesting the benefit on behalf of the member will be required to notify the member of approval and deliver a faxed copy of the approval.
- Typically, the requester is an ordering and/or rendering provider acting on behalf of the member. When verbal notice of an approval is given to the ordering and/or rendering provider, the provider is reminded to inform the member that the benefit has been approved by delivering the copy of the approval that SHP will fax to the requester. SHP will then document the reminder and faxed approval in its system.
Notice of Adverse (Not Approved/ Not Certified) Benefit Determination
- SHP may initially provide verbal notice of an adverse benefit determination to a member and ordering and/or rendering provider.
- SHP must follow up to provide written notice directly to the member and the ordering and/or rendering provider.
- SHP staff will call members in the hospital to communicate the denial of service. SHP then faxes the denial letter to the hospital and instructs hospital staff to provide the paper copy of denial to the member.