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  • SNF IRF LTAC > Prior Approval Process

    eviCore healthcare (eviCore) will begin accepting prior approval requests for post-acute care and direct admissions on December 28, 2017 for dates of service beginning January 1, 2018 for the following:

    • Skilled Nursing Facilities (SNF)
    • Inpatient Rehabilitation Facilities (IRF)
    • Long Term Acute Care Facilities (LTAC)

    After January 1, 2018: Members should not be transferred from an inpatient hospital setting to a SNF, IRF or LTAC setting without an eviCore prior approval number. SNF, IRF or LTAC facilities receiving EmblemHealth-managed members without prior approval should contact eviCore to verify approval before admission. Servicing facilities may obtain SNF, IRF or LTAC prior approval details for HIP Members via the eviCore web portal or by calling eviCore at 866-417-2345, option 3 for HIP, or option 5, then 2 for PAC.

    Who Requests Prior Approval

    • Hospitals will be responsible for submitting the initial post-acute care prior approval requests directly to eviCore for members being discharged to a SNF, IRF or LTAC.
    • SNF, IRF and LTAC will be responsible for submitting concurrent review requests to eviCore for existing admissions and new (initial) prior approval requests for community referrals.
    • SNF, IRF and LTAC are responsible for submitting the initial Home Health Service requests for all HIP members discharging from a their facility with home health services.

    How To Obtain a Prior Approval
    All providers must verify member eligibility and benefits prior to rendering services at The following sections describe the information you will need to submit to eviCore and the processes for submitting prior approval requests.

    Required Information

    The requesting provider should be prepared to submit:

    • Appropriate eviCore request form - available at:
    • Patient’s medical records
    • Details such as: admitting diagnosis, history and physical, progress notes, medication list and wound or incision/location
    How to Request Prior Approval For SNF/IRF/LTAC
    Managing Entity Methods to Submit Prior Approval Requests
    eviCore eviCore offers two convenient methods to request prior approval, depending on the Program:

    1. Call 866-417-2345, option 3 for HIP members, then 5 for PAC or Transitional Care; then either 2 for PAC or 3 for Transitional Care.

    2. Facsimile: Clinical documentation can be faxed to 855-488-6275.
    HealthCare Partners Call (800) 877-7587 or fax your request to (888) 746-6433.
    Montefiore CMO Call (888) 666-8326.

    Prior approval Skilled Nursing Inpatient Rehab Facility Long Term Acute Care
    Initial 3 calendar days 5 calendar days 5 calendar days
    Concurrent 7 calendar days 5 calendar days 7 calendar days

    Once clinical information is received, determinations will be made within 1 business day. If a peer to peer review is requested, an additional business day will be granted. However, eviCore’s typical response time is less.

    Once eviCore has made a determination, they will call the requesting facility with a notification. Determinations will be shared via Allscripts with hospitals that use Allscripts. A copy of the determination letter will also be faxed.

    The service facility can obtain the prior approval details via the eviCore web portal or by calling 866-417-2345. Use option 3 for HIP and Option 5, then 2 for PAC.

    The Initial prior approval is valid for 7 days. During that timeframe, inpatient hospitals must transfer the member to a SNF, IRF or LTAC facility. If the member is not discharged within the 7 day approval period, new prior approval is required.

    Date Extension (concurrent review) Requests:
    Important: For date extension (concurrent review) prior approval requests, facilities should submit clinical information 72 hours before the last covered day. This allows time for Notice of Medicare Non-Coverage (NOMNC) to be issued. eviCore will issue the NOMNC form to the provider. The provider is responsible for issuing the NOMNC to the member, having it signed and returning it to eviCore.

    SNF/IRF/LTAC Prior Approval Criteria

    Criteria used by eviCore includes, but is not limited to:

    • McKesson InterQual® Criteria
    • Medicare Benefit Policy Manuals & Clinical Findings

    Retrospective Reviews
    eviCore will accept requests for retrospective reviews of medical necessity. Requests must be submitted within 14 calendar days from the date the initial service was rendered.

    Concurrent Review
    Facilities that fail to provide clinical updates and/or progress notes to the managing entity (concurrent review nurse or eviCore) will not be reimbursed for unauthorized days.

    Hospital Transfers
    If an emergency occurs, the SNF, IRF or LTAC facility should take all medically appropriate actions to safely transport the member to the nearest hospital, including the use of an ambulance, if necessary.

    eviCore must be notified when a member temporarily leaves and returns to a SNF, such as when the member is readmitted to the hospital.

    Discharge Planning
    The discharge planning process from all facility settings should begin as early as possible. This allows time to arrange appropriate resources for the member's care.

    Hospitals will be responsible for submitting the initial prior approval requests directly to eviCore for members being discharged to a SNF, IRF or LTAC. For post-acute care services after an inpatient hospital stay (acute rehabilitation, skilled nursing facility stay, home care, durable medical equipment, etc.), the eviCore concurrent review nurse will facilitate prior approvals of medically necessary treatments if the member's benefit plan includes these services.

    For members in a SNF, IRF or LTAC, the discharging facility is responsible for submitting the initial Home Health Service requests.

    Notice of Medicare Non-Coverage (NOMNC) for Medicare Members
    Important: For date extension (concurrent review) prior approval requests, SNF Facilities should submit clinical information 72 hours prior to the last covered day. This allows time for Notice of Medicare Non-Coverage (NOMNC) to be issued. eviCore will issue the NOMNC form to the provider. The provider is responsible for issuing the NOMNC to the member, having it signed and returning it to eviCore.

    In accordance with CMS guidelines, the Notice of Medicare Non-Coverage (NOMNC) will be issued by the servicing provider no later than 2 calendar days prior to the discontinuation of coverage or the second to last day of service, if care is not being provided daily.

    If the member is cognitively impaired, the servicing provider is responsible for informing the health care proxy of the end-of-service dates and the appeal rights. If the proxy is unable to sign and date it, the staff member and witness who informed the proxy of the end date and appeal rights should sign and date the form, then fax it back to eviCore or send via the eviCore PAC Web Portal.

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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

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

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

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

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    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.

    The government agency responsible for administering the Medicare and Medicaid programs.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    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 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.

    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

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.

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

    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.

    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 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 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.

    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.

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

    A review done after services are completed (usually as part of a claim or appeal) that ensures the care given was medically necessary.

    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.


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