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Provider Manual

Hospital Observation Admission

Last Updated on November 01, 2018

Changes in the Hospital Observation Admission Process
Effective September 1, 2018

  • Notify Security Health Plan within 48 hours or the next business day of any observation admission greater than two midnight or 48 hours.
  • Fax the appropriate clinical information within 24 hours of notification of observation admission to Security Health Plan Health Services at 715-221-9980
  • 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.

Observation care is, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.

Claims submitted need to match the appropriate dates and level of care indicated for the authorization number(s) granted.  Example: On day one and two you receive authorization for observation. On day three 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 three.

  • If the provider fails to provide the needed clinical information within 24 hours of the notification of 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. The appeal process can be found here.

Pre-certification of Hospital Admissions

The provider, not the member, is responsible to precertify an admission to the hospital for medical and/ or surgical treatment.

  • Notify Security Health Plan at 1-800-548-1224 of all acute inpatient admissions within 48 hours of admission.
  • Fax the appropriate clinical information within 24 hours of notification of observation admission to Security Health Plan Health Services at 715-221-9980. If the provider fails to provide the needed clinical information within 24 hours of the notification of 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.

Based on medical diagnosis or proposed surgery and medical information, Security Health Plan will:

  • authorize coverage for a length of stay is based on InterQual Level of Care Guidelines. (Remember that these are a minimum length of stay consistent with quality care. Actual length of coverage for a stay is based on medical necessity and intensity of service)
  • 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. The appeal process can be found here.
  •  upon request, send a copy of the appropriate guidelines (available by contacting the Security Health Plan utilization management specialist).

Contact the Security Health Plan utilization review coordinator at 1-800-991-8109 (option #1 or #2) or 715-221-9768 or 715-221-9661.

Hospital responsibilities include:

  • Notify Security Health Plan at 1-800-548-1224 within 48 hours of all observation with length stay greater than 48 hours and acute inpatient admissions. 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.