Precertification Notification and Concurrent Review
- Precertify all elective inpatient admissions/surgeries
- Notify Security Health Plan at 1-800-548-1224 of all direct/urgent inpatient admissions done
- Provide the medical information necessary to evaluate inpatient admission
- Notify Security Health Plan with any date of service changes
- Notify Security Health Plan at 1-800-548-1224 of inpatient admissions and provide initial claim review within 24 hours of the first business day of admission to prevent penalty for late notification
- Provide timely concurrent review activities (telephonic and on-site) to prevent penalty for late notification
- Notify the Security Health Plan members orally of all organization determinations during the inpatient admission
- SNF must prior authorize skilled nursing facility admissions with naviHealth at (Phone) 855-512-7002 or (Fax) 855-847-7243
- If admission is after normal business hours, SNF must notify naviHealth within 24 hours of the admission or on the first business day after admission, whichever is sooner
- Cooperate with concurrent review activities (telephonic or on-site) which includes providing naviHealth with timely concurrent review within 24 hours of last certified day
- Failure to prior authorize SNF admission will cause the reimbursement period to begin on the day the Plan is notified. However, the member's actual admission day will be considered the first day of the benefit period. If Affiliated Facility fails to obtain prior authorization:
- the Plan will not reimburse Affiliated Facility for covered services incurred prior to the day the Plan is notified of the admission, and
- Affiliated Facility shall not bill, charge, collect a deposit from, seek remuneration or compensation from the Plan member, or any person acting on the member's behalf, for covered services incurred prior to the day the Plan is notified of the admission.
- Failure to obtain prior authorization means the Plan will not be able to perform timely concurrent review of the admission. The Plan will therefore not reimburse Affiliated Facility for covered services incurred prior to the performance of the concurrent review of the admission and Facility shall not bill, charge, collect a deposit from, seek remuneration or compensation from the Plan member, or any person acting on the member’s behalf, for covered services incurred prior to the performance of the concurrent review.
Precertification of hospital admissions
- authorize coverage for a length of stay based on InterQual Level of Care Criteria, 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.
Security Health Plan identifies Medicare Advantage members who were admitted inpatient to a DRG payment hospital and are readmitted to that same hospital within 24 hours. The 24 hours is defined as the time the member physically was discharged from the facility of 1st admission to the time the physician wrote the admission order for the readmission. Security Health Plan utilizes QIO Manual-Chapter 4-240 - Readmission Review - (Rev. 2, 07-11-03). Security Health Plan reviews both admissions utilizing the following criteria:
- Medical records from the previous hospital stay are obtained and reviewed.
- The DRG hospital subset for the current level of care must be reviewed.
- The DRG hospital subset for the previous admission must be reviewed.
- If discharge criteria for the 1st admission is met, 2nd DRG should be considered eligible for coverage.
- If discharge criteria for the 1st admission ARE not met, this case would be denied for circumvention of PPS
- If the readmission was medically unnecessary;
- If the readmission resulted from a premature discharge from the same hospital; or
- If the readmission was a result of circumvention of PPS by the same hospital