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Neighborhood Care

SNF IRF LTAC

03/29/2021

This program applies to post-acute care (PAC) services and direct admissions from the community for Health Insurance Plan of Greater New York (HIP), EmblemHealth Insurance Company (formerly HIP Insurance Company of New York (HIPIC)), and Bridge Program members. eviCore healthcare (eviCore) manages most PAC preauthorizations for these members.

Preauthorization may be needed before certain services can be rendered or equipment supplied. Depending on which networks members access and who has financial risk for their care, preauthorization requests are evaluated by eviCore, EmblemHealth, or the member’s assigned Managing Entity. For the list of Healthcare Common Procedure Coding System (HCPCS) codes requiring preauthorization, refer to Clinical Corner. 

 

Preauthorizations do not guarantee claims payment. Services must be covered by the member’s health plan and the member must be eligible at the time services are rendered. Claims submitted may be subject to benefit denial. Prior to rendering services, all providers must verify member eligibility and benefits at emblemhealth.com/providers.

Exempt Members

The following plans are exempt from the eviCore preauthorization process:

  • • EmblemHealth Plan, Inc. (formerly GHI) benefit plans
  • • Members whose ID card indicates a primary care physician from one of the following Managing Entities:
    • o HealthCare Partners (HCP)
    • o Montefiore CMO (CMO) 

Excluded members are medically managed in the same way as they are for other services by the assigned Managing Entity. Check the member’s ID card or eligibility information on emblemhealth.com/providers to determine the Managing Entity. See the Utilization and Care Management chapter of the Provider Manual for applicable rules and preauthorization processes. You may also use the Preauthorization Lookup Tool on the provider portal to determine if a preauthorization is required and who is responsible for conducting the review.

Community Referrals

eviCore provides utilization management for services requested.

Transitional Care Services

eviCore provides transitional care services for members discharging from the hospital with inpatient PAC services or home health care (HHC) services, except for those noted above. Members are managed by the eviCore Transitional Care Program for 90 days post-hospital discharge. The Transitional Care Program facilitates member support based on identified risk factors. Core services include PCP appointment scheduling, disease coaching, social services support, and member education. If the member’s skilled nursing benefit extends beyond 90 days, EmblemHealth handles utilization management and preauthorization. Refer to the Utilization and Care Management chapter.

Preauthorization Process

Services Requiring Preauthorization

eviCore performs preauthorization review for PAC and direct admissions for the following:

  • Skilled nursing facilities (SNF)
  • Inpatient rehabilitation facilities (IRF) 
  • Long-term acute care facilities (LTAC)

Members should not be transferred from an inpatient hospital setting to an SNF, IRF, or LTAC setting without an eviCore preauthorization number. SNF, IRF, or LTAC facilities receiving program members without preauthorization should contact eviCore to verify approval before admission. Servicing facilities may obtain SNF, IRF, or LTAC preauthorization details:

  • Online: evicore.com/provider
  • Phone: 866-417-2345, option 3 for HIP, or option 5, then 1 for Provider, then 5 for PAC

Who Requests Preauthorization

  • Hospitals are responsible for submitting the initial PAC preauthorization requests for members being discharged to an SNF, IRF, or LTAC. 
  • SNF, IRF, and LTAC providers are responsible for submitting:
    • Concurrent review requests for existing admissions. 
    • Initial preauthorization requests for community referrals. 
    • Initial HHC service requests for members discharging from their facility with home health services.

How to Obtain a Preauthorization

Below is the information you need and the process for submitting preauthorization requests to eviCore.

The requesting provider should be prepared to submit:

  • The appropriate eviCore request form 
  • Patient’s medical records
  • Details such as: 
    • Admitting diagnosis
    • History and physical
    • Progress notes
    • Medication list
    • Wound or incision/location

eviCore offers two (2) convenient methods to request preauthorization:

  1. Call 866-417-2345, option 3 for HIP members, then option 1, then option 5 for PAC or Transitional Care; then either 2 for PAC or 3 for Transitional Care.
  2. Fax clinical documentation to 855-488-6275.

Preauthorization Time Frames

eviCore provides preauthorization for set periods of time by service type in the following ways:

 

Preauthorization 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 are made within one (1) business day. If a peer-to-peer review is requested, an additional business day is granted. However, eviCore’s typical response time is less.

 

Once the determination is made, eviCore provides verbal notification to the requesting provider. Determinations are shared via Allscripts with providers that use Allscripts services. A copy of the determination letter is also faxed.

 

The initial preauthorization is valid for seven (7) days. During that time, inpatient hospitals must transfer the member to an SNF, IRF, or LTAC facility. If the member is not discharged within the seven (7)-day approval period, a new preauthorization is required.

 

SNF/IRF/LTAC Prior Approval Criteria

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

  • MCG Health (fka Milliman Care Guidelines) – for cases on and after Sept. 1, 2020
  • McKesson InterQual® Criteria – for cases prior to and including Aug. 1, 2020
  • Medicare Benefit Policy Manuals & Clinical Findings

 

Retrospective Reviews

eviCore accepts 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) are not 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 an 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 are responsible for submitting the initial preauthorization requests directly to eviCore for members being discharged to an SNF, IRF, or LTAC. For PAC services after an inpatient hospital stay (acute rehabilitation, skilled nursing facility stay, home care, and durable medical equipment), the eviCore concurrent review nurse facilitates preauthorization of medically necessary treatments if the member’s benefit plan includes these services.

 

For members in an SNF, IRF, or LTAC, the discharging facility is responsible for submitting the initial HHC service requests.

 

Notice of Medicare Non-Coverage (NOMNC) for Medicare Members

Important: For date extension (concurrent review) requests, SNFs should submit clinical information 72 hours prior to the last covered day. This allows time to issue the Notice of Medicare Non-Coverage (NOMNC). eviCore issues 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 servicing provider issues the NOMNC no later than two (2) calendar days prior to the discontinuation of coverage or the second to last day of service, if care is not being provided daily.

 

The servicing provider is responsible for informing members who are cognitively impaired of the health care proxy of the end-of-service dates and the appeal rights. If the proxy is unable to sign and date the NOMNC, 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.

Denial and Appeal Process

Denial of Preauthorization

Cases that do not meet medical necessity on initial nurse review are sent to a second-level physician for review and determination. If the eviCore physician makes a potential adverse determination, the requesting facility is contacted and offered a peer-to-peer (P2P) review.

 

P2P must be requested within one (1) business day or a denial letter is issued. Any additional clinical information that supports medical necessity must be received within one (1) business day. If not, the determination is final, and the case is closed.

 

If the P2P process does not result in a reversal of the denial recommendation, eviCore issues a denial letter. The physician reviewer may suggest an alternate level of care and/or the appeals process. Once a service is denied, members and providers must file an appeal to have the request reviewed again.

 

Denial of Extended Services 

Cases that do not meet medical necessity on concurrent nurse review are sent to a second-level physician for review and determination. If the eviCore physician makes a potential adverse determination, the requesting facility is contacted and offered a P2P as described above.

 

IRF Date Extensions: P2P must be requested within one (1) business day or a denial letter will be issued. Any additional clinical information that supports medical necessity must be received within one (1) business day. If not, the determination is final, and the case is closed.

 

SNF Date Extensions (Concurrent review requests): The NOMNC is issued no later than two (2) calendar days prior to the discontinuation of coverage. The third (3rd) calendar day is not covered unless the decision is overturned or the NOMNC is withdrawn. P2P must be requested and occur within the two (2)-calendar-day time frame. If P2P does not occur or if the decision is upheld, the member is responsible for paying the continued stay if they choose not to discharge on the third (3rd) calendar day.

 

If a member appeals the end-of-stay decision through Island Peer Review Organization (IPRO), the SNF is responsible for sending the medical records to IPRO by the end of the day on which they are requested. IPRO is open seven (7) days a week to take appeal information.

 

Reconsideration Process (Commercial and Medicaid only)

A reconsideration is a post-denial, pre-appeal opportunity to provide additional clinical information. Reconsideration (P2P) must be requested within 14 days of the initial denial date. P2P requests can be made verbally or in writing. P2P is conducted with the referring physician and one of eviCore’s Medical Directors. P2P results in either a reversal or an uphold of the original decision. The requestor and the member are notified via mail and fax.

 

Appeals Process (Medicare, Medicaid, and Commercial)

eviCore handles first-level Commercial and Medicaid appeals. Medicaid or Commercial members may request an appeal by following the instructions in the denial letter. Providers should submit appeal requests to eviCore via:

  • Phone at 800-835-7064, Monday through Friday, 8 a.m. - 6 p.m.
  • Fax to 866-699-8128

EmblemHealth handles Medicare appeals. Medicare members may request an appeal by following the instructions in the denial letter. Providers should follow the process in the Dispute Resolution for Medicare Plans chapter of the Provider Manual.

 

Turnaround time after an appeal has been requested by the member is as follows:

  • Expedited: up to 72 hours 
  • Standard: up to 30 days

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.