Provider Portal - Create Emergent Inpatient Admission Notifications

STOP: If EmblemHealth is not the member’s Managing Entity, you must notify the Managing Entity directly. They are responsible for conducting concurrent review for the member’s inpatient stay. See detailed instructions for finding the member.

TIP: From the search results table, select the row with an Active Status and Medical Coverage Type.

On this screen the user will also be prompted to check off two items to acknowledge:

1. The notification will not be considered submitted until all required clinical information is provided and the Submit Notification button at the end of the transaction is clicked to begin the concurrent review of the inpatient stay.

2. That by choosing to save a draft, one will be available for 120 hours. During this time, authorized users will be able to see, contribute to, and submit the preauthorization request.

On this screen you will search for and select the inpatient facility where the member has been admitted. You will see a pop-up alert if an out-of-network provider is selected. See detailed instructions for finding the facility.

TIP: We recommend searching by NPI.

The Admitting Provider is the doctor or practitioner who is responsible for the member’s care. See detailed instructions for finding the admitting provider.

On this screen you will enter the primary and secondary Diagnosis Codes. See detailed instructions for finding Diagnosis Codes.

The Primary diagnosis code is mandatory while secondary diagnosis codes are optional. Use the Secondary Diagnosis Codes section to search for and add up to 11 secondary diagnoses. Between diagnoses, click Add to enter the next code.

NOTE: The diagnosis codes entered here will determine which MCG/Clinical Guideline(s) the portal will expect to be addressed in Part Two.

TIP: If the notice is saved as a draft and the diagnosis changes before the clinical information is entered, we recommend restarting with a new notice so the portal can prompt you for the applicable clinical criteria.

Enter the information for the person EmblemHealth or ConnectiCare should call if we need more information. You may also be prompted with an option to have the identified Contact receive notification of the determination by email.

If the person who starts the notice does not submit it, the identified Contact will receive an email letting them know a draft is active and needs attention. The Contact will also receive an email if the draft is not completed and expires.

You will be given the option of continuing or saving a draft for 120 hours.

Reminder emails: If you save a draft, the identified Contact will be sent an email reminder before the draft expires. If no action is taken after the reminder, another email will be sent notifying the Contact that the draft expired.

On the Incomplete Preauthorization Requests and Emergent Inpatient Admission Notifications page, you will be able to locate both the active and expired drafts submitted in the last 30 days.

To find a draft for a specific member, enter the Member ID or Member Name in the Filter By box, or sort on the Member ID or Member Name column and scroll through the table.

If the draft is expired, the Draft Number will no longer be a functioning link and the Draft Retained Until column will show a date/time that is more than 120 hours past the Draft Initiated date/time.

If the member was admitted to the hospital from the emergency room, a new notification should be submitted even if the member has already been discharged.

Anyone who is associated with the notice will be able to find a copy of the draft to complete the clinical information, attach supporting documentation, and submit the notice.

To be associated with the notice, you must have the Administrator/Office Manager or Clinical Staff role and be linked to the tax ID for the:

• Requesting Provider
• Requesting Facility
• Servicing Provider
• Servicing Facility
• Discharging Facility

The diagnosis code entered determines which MCG/Clinical Guidelines will be required. If guidelines are required, you will see orange Document Clinical button(s) you will need to address by checking off the clinical criteria that apply to the notification. You must also click the blue Attach File button to share supporting documentation such as medical records and test results.

WARNING! The Submit Request button will remain inactive until each Document Clinical button is addressed and expected documentation attached. Once the clinical information is entered and all documents are attached, you must click the Submit Request button to finish the transaction.

Once you click the Document Clinical button, you will be shown a list of potential clinical guidelines that may apply.

Example: Diagnosis M54 Dorsalgia where the Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy guideline applies.

To pick the guideline for the diagnosis M54 Dorsalgia, click add in the Action column for the Guideline Title Cervical Diskectomy or Microdiskectomy, Foraminotomy, Laminotomy.

Once a guideline is selected, you will be shown criteria that could apply.

1. Click all boxes that apply to your patient.

2. If you see this Add Notes symbol, you can click it to see a pop-up screen where you can add notes up to 250 characters in length.

Once appropriate criteria have been selected and notes entered, click the Save button.

Select Guideline

Select Applicable Criteria

NOTE: If the Document Clinical button displays, but on the next screen you do not see an applicable guideline or are unsure of which guideline to choose, click add in the Action column for “No Guideline Applies”. This will display a notes screen. Describe the reason why the listed guidelines are not appropriate and why the member needs the services.

If you do not have full clinical information, you may use the Back button to save the information entered. You will still have the remainder of the 120 hours to finish adding the clinical information and submit the request.