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  • Care Management > Utilization Reviews - Inpatient Care

    EmblemHealth and utilization review health care professionals make initial utilization review determinations for requested health care services that require prior approval. A "pre-service request" is a request for a service that must be pre-authorized by EmblemHealth.

    Standard Pre-Service Review

    Commercial/Child Health Plus
    We will notify the member, their designee and their health care provider regarding a pre-service request within three business days after our receipt of the request if the information provided is or becomes complete. Notification will be in writing and by telephone to the member and provider. If EmblemHealth requires more information to make a determination, EmblemHealth will request such information within 15 days after its receipt of the request. EmblemHealth will provide at least 45 days to supply the information. At the end of the 45-day period, if the complete information is not received a determination will be made based on the information received within 15 calendar days from the expiration of the 45-day period.

    Medicaid/Family Health Plus
    We will notify the member, their designee and their health care provider regarding a pre-service request within three business days after our receipt of all the necessary information, but no more than 14 calendar days from receipt of request. Notification will be in writing and by telephone to the member and provider. This may be extended for up to 14 calendar days.

    Medicare
    Providers and members will be notified in writing of a determination within 14 calendar days after we receive the request. This may be extended for up to 14 calendar days.

    Urgent/Expedited Review

    Commercial/Medicaid/Family Health Plus and Child Health Plus
    EmblemHealth may reasonably require the provider or member to explain the medical reasons that give rise to a need for urgent care. If care has not yet been initiated, EmblemHealth will notify the provider and member of its decision regarding the urgent care claim within 72 hours from receipt of the request. Notification will be in writing and by telephone to the member and provider.

    If we require more information to make a decision, then we will request the additional information within 24 hours after we receive the request. We will provide at least 48 hours to supply the information. Notification of our determination will occur within 48 hours of our receipt of the information or within 48 hours of the end of the time period we provide to supply the information. For Medicaid and FHPlus members this time frame may be extended for up to 14 calendar days.

    Medicare Advantage
    Providers and members will be notified of a determination within 72 hours after we receive the request. If the request does not meet the criteria for an expedited request, the individual will be notified and the request will automatically be transferred to a standard request. A determination will be made within 14 days of the date that the request becomes a standard request.

    Failure to make an initial utilization review determination within the specified times may be deemed as an adverse determination and subject to appeal/action appeal.

    To be considered for payment, approval for elective services must be completed before services are rendered.

    Admission Review and Concurrent Review

    Once an initial inpatient stay or hospitalization has been issued, it is the responsibility of the facility to provide the managing entities (e.g., the EmblemHealth concurrent review nurse) with the necessary clinical updates. Facilities may submit concurrent review information to EmblemHealth via secure email or fax.

    We may conduct concurrent reviews for members who are receiving care in an inpatient setting from the date of admission or for members who are receiving on-going care in an outpatient setting. Such concurrent review may result in our denial of payment based on eligibility, coverage or medical necessity for such covered care. For admissions that are reimbursed under a DRG methodology, concurrent utilization review may be conducted to determine medical necessity for quality purposes and discharge planning.

    Once we have been notified of the admission, the concurrent review process will begin. The member's case will be assigned to a concurrent review nurse who will be responsible for requesting and initially reviewing all pertinent clinical information, including consulting with the treating physician and reviewing medical records, to determine the medical necessity of the services being provided. Concurrent review nurses perform telephonic or fax reviews with contracted hospitals. Concurrent review of the hospital stay may occur daily, depending upon the patient's acuity status.

    The review frequency for any given case is determined by contractual agreements, payment methodology, discharge planning activity and the complexity of the patient's clinical condition. Concurrent review will not be conducted more frequently than is reasonably required to assess whether the health care services under review are medically necessary.

    During the concurrent review, the concurrent review nurse maintains contact with the attending physician, hospital discharge planner, care manager if needed, patient and/or family members to address any anticipated medical services or sub-acute options (such as home care) and coordinates the appropriate referrals to participating alternate care facilities.

    If the review does not meet medical necessity criteria, the concurrent review nurse reviews the case with an EmblemHealth medical director who will render a decision. Whether the stay is approved or denied as not medically necessary, the concurrent review nurse notifies all applicable parties (i.e., the attending physician, the facility and the member) by telephone and/or fax within one working day of making the decision, and gives members and practitioners written or electronic confirmation within 24 hours if the request is received 24 hours prior to the end of the current approved period. If the request is received less than 24 hours before the end of the current approved period, the determination and notification will be made within one business day of receipt of all necessary information but no more than 72 hours from receipt of request.

    Hospital utilization reports are reviewed by the Care Management department for analysis and system-wide action plan recommendations to the Quality Improvement Committee (QIC) through the Care Management Committee.

    If the review is for post-acute hospital care and it meets medical necessity criteria and the member has the benefit, the service will be approved and would be monitored by either the Post-Acute Services department or the Continuing Care Services program.

    The status of each case (whether approved, denied or pended) is included on the Concurrent Review Status Report posted to the secure provider site at www.emblemhealth.com for HIP-contracted hospitals and skilled nursing facilities.

    Note: Medicare members do not require prior approval for hospice care. Hospice services are covered by FFS Medicare for Medicare members. For Medicare members receiving hospice services, EmblemHealth provides benefits for services not related to the terminal illness. Medicare members may revoke their hospice election at any time and return to the Plan to receive care related to their terminal illness.

    Post-Service Review

    (In the event the participating hospital does not notify the plan on admission)

    Commercial/Child Health Plus
    When a claim is submitted for an admission through the emergency department without the plan having received timely notification, records will be requested from the facility for an initial retrospective clinical review by the plan's Post-Service Review department. Upon the plan's request for medical records, the facility is given 30 days to submit the records. If records are received within that 45 calendar days from receipt of request, they are reviewed for medical, and a decision is made and communicated to the provider and the member in writing within 15 calendar days of receipt of the requested clinical information. If the case is denied (in whole or in part), appropriate appeal rights will be included.

    Medicaid/Family Health Plus/Medicare
    When a claim is submitted for an admission through the emergency department without the plan having received timely notification, records will be requested from the facility for an initial retrospective clinical review by the plan's Post-Service Review department. Upon the plan's request for medical records, the facility is given 30 days to submit the records. A clinical determination will be made within 30 calendar days from receipt of request and is communicated to the provider and the member in writing within the determination time frame. If the case is denied (in whole or in part), appropriate appeal rights will be included.

    Failure by the plan or the utilization review agent to make a determination within the time periods prescribed in this section shall be deemed to be adversely determined and subject to appeal.

    Adverse Determination Process

    If the Care Management program does not make an initial determination within the specified regulatory time frames of receiving all necessary information, the member, member's designee or the clinician on behalf of the member may exercise their next level of appeal rights regarding their service request.

    If a service or continued use of a service is not medically necessary or appropriate based on a review of the clinical findings by the medical director, and following discussion with the attending physician, the plan medical director may make the decision to deny coverage of a service or further service for that episode of care. The nurse and/or medical director will attempt to contact the attending physician to allow the physician an opportunity to discuss the case with the medical director. The medical director will not make an adverse determination until all efforts have been made to resolve issues with the attending physician.

    When the decision is made to deny coverage of a service or further service for an episode of care, an attempt will be made to contact the treating physician by telephone. The treating physician will be given the telephone number of the EmblemHealth physician reviewer or utilization review agent and is afforded the opportunity to speak with the reviewer about the denial.

    The appropriate parties (physician, facility representative, patient, patient's family or legal guardian) will be notified in writing of an adverse determination. The notification will include the reasons for the adverse determination, including the clinical rationale and instructions on how to appeal the determination. This notice will also inform the clinician of the availability, upon request of the member or the member's designee, of the clinical review criteria relied upon to make the determination and specifies what, if any, additional information must be provided for the Plan or the review agent to render a decision upon the appeal. The adverse determination letter advises the physician about the opportunity to speak with the EmblemHealth medical director or utilization review agent who rendered the decision to discuss the denial along with a phone number where the medical director can be contacted.

    Reconsideration Process

    Whenever an adverse determination is rendered, with or without the input of the clinician, the clinician has the opportunity to request a reconsideration of the adverse determination. Such reconsideration shall occur within one business day of receipt of the request (except retrospective) for reconsideration and shall be conducted by discussion between the clinician and the EmblemHealth medical director who rendered the decision or a designated clinical peer reviewer. Note: This process does not apply to Medicare members. An actual appeal must be submitted for Medicare members. Please see the Dispute Resolution chapters for more information.

    Medicare Member Notices of Non-Coverage (GRIJALVA Process)

    If the member no longer meets medical necessity criteria, notice of Medicare non-coverage will be issued to the Medicare member for continued skilled nursing facility (SNF) stays, home health care services or certified outpatient rehabilitation facility (CORF) services. If the notice of non-coverage is issued to a Medicare patient and the patient objects to the notice of non-coverage, the notice becomes effective two days after the day of issuance, unless the Medicare patient requests quality improvement organization (QIO) or IPRO for New York State review by noon of the first day following receipt of the notice. The QIO reviews the request and makes a determination within one working day of receipt of the request with the hospital or home care records, and notifies the member of its decision. If the QIO upholds the adverse determination of continued coverage, the member will become liable for all costs commencing at noon of the day following receipt of the QIO determination.

    Restrospective Utilization Review

    Initial review, post-discharge, of a case wherein the claim was denied for no prior approval or for which no concurrent review was performed:

    • Whoever is responsible for managing the case (i.e., the managing entity) will perform the facility retrospective utilization review.
    • The managing entity will render a decision within 30 days of receipt of the retrospective utilization review.

    Note: While in the case of "no information denials," no true concurrent review is performed, such cases receive an initial clinical adverse determination (i.e., unable to establish medical necessity) and are therefore considered to have been reviewed. These denials, then, are subject to clinical appeals as indicated below, and not to retrospective utilization review.

    Adverse Determination Based on Information Submitted

    The following applies in the scenarios outlined below when we have received the necessary information to review the case for medical necessity:

    Prior to Discharge (Facility Reconsideration)

    If facility provides additional information after a denial has been issued but member has not yet been discharged:

    • Plan/managing entity will perform concurrent review and uphold or rescind decision as indicated
    • Reconsideration will be for all days for which information is supplied

      Expedited Appeal Process

      See the Dispute Resolution chapters of this manual: Commercial/Child Health PlusMedicaid/Family Health Plus or Medicare.

      Risk Identification and Management

      The objectives of risk identification and management are to identify and create an awareness of possible risks that may be potentially harmful to members, visitors, or employees, and to reduce the probability of unplanned or unexpected financial loss. Through integration with the Quality Management process, the overall goals are to proactively prevent harm and identify trends.

      All risk issues are referred to the Quality Management department for evaluation of potential quality of care issues. Those cases requiring immediate intervention are referred to a Medical Director, and substantial issues and trends are reported to the Clinical Quality Improvement Committee.

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      Glossary terms found on this page:

      An activity of EmblemHealth or its subcontractor that results in:

      • Denial or limited authorization of a service authorization request, including the type or level of service
      • Reduction, suspension or termination of a previously authorized service
      • Denial, in whole or in part, of payment for a service
      • Failure to provide services in a timely manner
      • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

      Oral or written request for EmblemHealth to review or reconsider an action by EmblemHealth or its subcontractor.

      Formal acceptance as an inpatient by an institution, hospital or health care facility.

      A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.

      Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.

      The physician primarily responsible for the care of a patient during hospitalization. The physician is licensed, board-certified or board-eligible and qualified to practice in the area appropriate to treat the member's life-threatening or disabling condition or disease. The attending physician must be a network provider with EmblemHealth or one to which EmblemHealth has referred the member.

      Services that have been approved for payment based on a review of EmblemHealth's policies.

      Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

      An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

      A physician who possesses a current and valid license to practice medicine or a health care professional other than a licensed physician who:

      • Where applicable possesses a current and valid nonrestricted license, certificate or registration or, where no provision for a license, certificate or registration exists, is credentialed by the national accrediting body to the profession
      • Is in the same profession and the same or similar specialty as the health care provider who typically manages the medical condition or disease or provides the health care service or treatment under review

      A statement that provides additional clarification of the clinical basis for a noncertification determination. The clinical rationale should relate the noncertification determination to the patient's condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.

      Occurs when a clinical professional reviews information about a patient's health.

      The written screens, decision rules, medical protocols or guidelines used by the utilization management agent as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures and services under the auspices of the applicable health benefit plan.

      Utilization review activities performed by a utilization management agent that include evaluation of requests for prior approval where necessary for covered services.

      A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

      A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

      A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

      Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

      A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

      Oral or written request to review or reconsider an initial adverse determination when waiting for a standard decision could seriously harm the enrollee's life, health or their ability to regain maximum function. For pre-service expedited requests, the practitioner may act on behalf of the member. Also called a fast track appeal.

      A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

      A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

      Health care services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupational or speech therapy, medical supplies and medication prescribed by a doctor.

      A facility or service that provides care for the terminally ill patient and support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

      An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

      • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
      • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
      • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
      • Maintains medical records for all patients
      • Has a requirement that every patient be under the care of a member of the medical staff
      • Provides 24-hour patient services
      • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

      Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

      Treatment provided to a patient who stays overnight (24 hours or more) in a hospital or other facility.

      An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

      Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

      A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

      A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

      Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

      • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
      • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
      • It is in accordance with accepted standards of good medical practice in the community.
      • It is furnished in a setting commensurate with the member's medical needs and condition.
      • It cannot be omitted under the standards referenced above.
      • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
      • It is not furnished primarily for the convenience of the member, the member's family or the provider.
      • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

      The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

      Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

      A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

      An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program. Also known as MA.

      An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

      A hospital that is part of EmblemHealth's provider network and has signed an agreement to provide covered services to its members. More commonly referred to as a network hospital.

      A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

      A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

      The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

      A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

      • Doctor of medicine
      • Doctor of osteopathy
      • Dentist
      • Chiropractor
      • Doctor of podiatric medicine
      • Physical therapist
      • Nurse midwife
      • Certified and registered psychologist
      • Certified and qualified social worker
      • Optometrist
      • Nurse anesthetist
      • Speech-language pathologist
      • Audiologist
      • Clinical laboratory
      • Screening center
      • General hospital
      • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

      A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

      The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.

      A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.

      A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

      A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a SNF.

      A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a skilled nursing facility.

      Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.

      A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.

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