The care management process is intended to establish and support a strong patient care team approach, which results in higher quality of care and lower costs. This process includes, but is not limited to, prior approval of facility admissions, concurrent management in the hospital, use of alternate care facilities and post-discharge follow-up.
Elective Inpatient Procedures - Admitting Physicians
The admitting network physician is required to obtain prior approval for elective inpatient procedures at least 10 business days in advance of the desired hospital admission date. This allows us sufficient time to obtain the necessary clinical information to process the request and to make appropriate arrangements for members (e.g., booking the facility space for the procedures and securing all lab work).
Physicians can confirm the prior approval status of an admission for a HIP-, CompreHealth EPO (Retired August 1, 2018) - or EmblemHealth-managed member by signing in to www.emblemhealth.com or calling 1-866-447-9717.
If the admitting physician is out-of-network, the member is responsible for contacting the plan for prior approval. For more information, see the How To Obtain a Prior Approval and Referrals and Elective Hospital Prior Approvals by Plan tables in this chapter.
Elective Admission Procedures - Hospitals and Facilities
(Including Acute, Inpatient Rehabilitation and Psychiatric Facilities)
The admitting facility (including hospitals) must confirm there is a prior approval on file for all elective, non-emergent admissions and ambulatory procedures.
In the event the facility is aware that the planned admission/procedure date has changed within a 90-day period, the facility should notify the plan of the new date(s) and ask the plan to modify the date(s) of the prior approval. An anticipated care report will be faxed daily to the facility listing those days/services that have been approved. If no services were approved for the facility, no report will be sent. (See the sample report at the end of this chapter.)
The facility must ask to see the member's ID card upon admission. The ID card will provide line of business information as well as the managing entity's information for requesting prior approval and submitting claims. The facility must verify member benefit and eligibility information by signing in to www.emblemhealth.com or as indicated in the Confirm Member Eligibility table in the Your Plan Members chapter.
If no prior approval has been issued where one is required, the claim submitted will be denied. Please see the Dispute Resolution chapters - Commercial/CHP, Medicaid, and Medicare - for information on denial determinations.
Should the facility feel that an overnight stay is warranted for an outpatient service, the plan must re-evaluate the admission for medical necessity. All necessary information must be submitted to the managing entity for re-approval.
The care management process is intended to establish and support a strong patient care team approach, which results in higher quality of care and lower costs. This process includes, but is not limited to, prior approval of facility admissions, concurrent management in the hospital, use of alternate care facilities and post-discharge follow-up.
Elective Inpatient Procedures - Admitting Physicians
The admitting network physician is required to obtain prior approval for elective inpatient procedures at least 10 business days in advance of the desired hospital admission date. This allows us sufficient time to obtain the necessary clinical information to process the request and to make appropriate arrangements for members (e.g., booking the facility space for the procedures and securing all lab work).
Physicians can confirm the prior approval status of an admission for a HIP-, CompreHealth EPO (Retired August 1, 2018) - or EmblemHealth-managed member by signing in to www.emblemhealth.com or calling 1-866-447-9717.
If the admitting physician is out-of-network, the member is responsible for contacting the plan for prior approval. For more information, see the How To Obtain a Prior Approval and Referrals and Elective Hospital Prior Approvals by Plan tables in this chapter.
Elective Admission Procedures - Hospitals and Facilities
(Including Acute, Inpatient Rehabilitation and Psychiatric Facilities)
The admitting facility (including hospitals) must confirm there is a prior approval on file for all elective, non-emergent admissions and ambulatory procedures.
In the event the facility is aware that the planned admission/procedure date has changed within a 90-day period, the facility should notify the plan of the new date(s) and ask the plan to modify the date(s) of the prior approval. An anticipated care report will be faxed daily to the facility listing those days/services that have been approved. If no services were approved for the facility, no report will be sent. (See the sample report at the end of this chapter.)
The facility must ask to see the member's ID card upon admission. The ID card will provide line of business information as well as the managing entity's information for requesting prior approval and submitting claims. The facility must verify member benefit and eligibility information by signing in to www.emblemhealth.com or as indicated in the Confirm Member Eligibility table in the Your Plan Members chapter.
If no prior approval has been issued where one is required, the claim submitted will be denied. Please see the Dispute Resolution chapters - Commercial/CHP, Medicaid, and Medicare - for information on denial determinations.
Should the facility feel that an overnight stay is warranted for an outpatient service, the plan must re-evaluate the admission for medical necessity. All necessary information must be submitted to the managing entity for re-approval.
Emergency Admission Procedures
If a member presents at a hospital emergency room and needs to be admitted, the hospital is required to notify the member's PCP immediately and to notify the member's managing entity listed on the back of the ID card within 24 hours or as soon as practicable thereafter. Following are ways to notify us of an emergency admission:
- Contracted hospitals may notify HIP and the managing entities, SOMOS, HealthCare Partners and Montefiore CMO, electronically of all admissions through the emergency room by signing in to www.emblemhealth.com for HIP, GHI HMO, CompreHealth EPO (Retired August 1, 2018) and Medicare HMO members. Benefits of electronic notifications are:
- 24/7 access.
- Automatic date/time-stamped receipt immediately sent back as proof of the notification.
- Immediate confirmation of member eligibility.
- Automatic and immediate routing for those cases managed by another entity on HIP's behalf; includes date/time stamp of notification to HIP.
- PCP name and contact information provided.
- Ability to follow status of inpatient case at www.emblemhealth.com. As soon as a notification is submitted, an inpatient case is created and assigned the same trace number referenced on the ER Admission Notification Receipt. For HIP-managed members, hospitals may use the trace number to find the inpatient case using the prior approval inquiry features. All cases appear in a pended status until all necessary information is received and concurrent review is performed.
- Contacted hospitals may notify HIP of emergency admissions for HIP, GHI HMO, CompreHealth EPO (Retired August 1, 2018) and Medicare HMO members by calling 1-866-447-9717 or faxing the notification to 1-866-215-2928.
- Contracted hospitals may notify Vytra by calling 1-888-288-9872.
- Contracted hospitals must notify GHI EPO/PPO and EmblemHealth EPO/PPO plans by calling 1-800-223-9870 or faxing the notification to 1-212-563-8391.
Note: Our plans do not require prior approval for an admission through the emergency room; rather, we require notification so that the case may be reviewed on a concurrent basis. No authorization number is required, and the managing entity will not issue an authorization and/or case number until the case has been reviewed for medical necessity.
If the facility fails to notify the managing entity of an admission through the emergency room, the managing entity will request medical records upon receipt of the claim and conduct a retrospective utilization review for medical necessity. Please see the Dispute Resolution chapters - Commercial/CHP, Medicaid, and Medicare - for information on denial determinations.
A member's PCP should respond to the hospital emergency room page within 30 minutes. If the hospital attempts to contact the member's PCP and does not make contact within 30 minutes, the hospital is instructed to contact the managing entity listed on the member's ID card for assistance in locating the PCP. The responding managing entity will obtain all relevant clinical information about the member.
Inpatient transfers between acute care hospitals/facilities
When a hospital or acute care facility does not have the services to ensure safe and/or quality care, it is the responsibility of the referring facility to contact the managing entity for all patient transfer requests by calling or faxing the applicable organization listed below:
Managing Entity/Members |
Phone |
Fax |
---|
EmblemHealth for HIP members |
866-447-9717 |
866-215-2928 |
EmblemHealth for Non-City of New York members and GHI retirees |
800-223-9870 |
212-563-8391 |
GHI PPO City of New York members and non-Medicare eligible retirees with GHI PPO benefits, contact Empire BCBS |
800-521-9574 |
800-241-5308 |
HealthCare Partners (HCP)-managed members |
800-877-7587 |
888-746-6433 |
Montefiore (CMO)-managed members |
888-666-8326 |
n/a |
SOMOS |
844-990-0255 |
877-590-8003 |
When contacting us, please have the following information available:
- Member ID number
- Member name
- Name of hospital/acute care facility accepting patient
- Name of physician accepting patient (from accepting hospital)
- Name of physician transferring care (from transferring hospital)
- Name of referring hospital/acute care facility
- Diagnosis
- Reason for transfer
For EmblemHealth-managed HIP and GHI members, a concurrent review nurse will review and refer all requests to an EmblemHealth Medical Director for a determination based on the clinical urgency of the specific situation. A decision will be made within one (1) business day, or in the case of a weekend on the same day of receiving all requested information. If the transfer request is approved, the concurrent review nurse will contact the transferring facility and issue a case number for the transfer.
It is the accepting hospital/acute care facility’s responsibility to confirm the transfer is authorized and to obtain the case number from the transferring facility. To receive payment, the accepting facility must include the case number on all associated claim submissions.
If the request for the transfer is denied, refer to the applicable Dispute Resolution chapters - Commercial/CHP, Medicaid, and Medicare.
Concurrent Review (Non-DRG Inpatient Stays)
Once a member is admitted to a facility, the applicable Managing Entity will reach out to the facility for clinical information to evaluate the ongoing medical necessity of the inpatient stay. Facilities are allowed 24 hours to provide the requested information. Decisions will be made based upon available information. EmblemHealth follows industry standard medical care guidelines (found at www.MCG.com) to determine the appropriate review frequency. Ongoing requests for clinical information will be made consistent with the goal length of stay expected for the admission. Facilities should expect to receive requests for additional information approximately 24 hours before the expected goal length of stay has expired. If the requested information is not provided, the day will be denied with a provider/facility denial. The member may not be billed for this day.
Concurrent Review (DRG Inpatient Stays)
For inpatient stays after July 20, 2020 that fall under a diagnosis-related group (DRG) payment system, facilities only need to provide clinical information to the Managing Entity for the initial length of stay and for discharge planning, unless:
- The facility plans to bill charges in addition to the DRG (commonly referred to as “outlier charges”).
- The facility requests a review where:
- a member’s circumstances are unique (such as they have had a Transplant or were admitted to the NICU).
- a prolonged hospital stay is expected, and outlier charges are likely to apply.
- the circumstances around a member’s stay or discharge are more complex than normally expected for the diagnosis.
- the member needs case management.
- the member does not feel comfortable leaving the facility even though it is medically appropriate.
Concurrent Review Status Report
The Concurrent Review Status Report (see an example at the end of this chapter) will be posted to our secure website at www.emblemhealth.com, Monday through Friday (excluding holidays), twice a day between 10 am and 5 pm ET. This report lists each admitted member and whether the current day is approved, denied, or pending further information. Pending information means we require additional information to make a determination. If the requested information is not provided, the day will be denied with a provider/facility denial. The member may not be billed for this day. For inpatient stays paid via a DRG methodology, please see the Concurrent Review (DRG Inpatient Stays) section above for cases where a member needs to stay beyond the approved length of stay.
Emergency Services for Out-of-Area
Medicaid and Commercial members are covered for emergency care in all 50 United States, Canada, Puerto Rico and the United States Territories of the Virgin Islands, Guam, American Samoa and the Northern Marianna Islands. Medicare members are covered for emergency care worldwide. In an emergency that meets this definition, members in one of these areas can go to the nearest emergency room or call 911.
In-Hospital Services
All in-hospital services and ancillary support should be provided by network physicians.
See the Use of Out-of-Network Providers subsection in the Care Management chapter.
Medicare Outpatient Observation Notice MOON
On August 6, 2015, Congress enacted the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which requires all hospitals and critical access hospitals (CAHs) to provide written notification and an oral explanation of such notification to individuals receiving observation services as outpatients for more than 24 hours. A standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611 was developed to inform all Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH.
In accordance with the statute, the notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services. Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged, or admitted.
All hospitals and CAHs are required to provide this statutorily required notification no later than March 8, 2017. The notice and accompanying instructions are available at:
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html
Discharge Planning
The discharge planning process should begin as soon as possible to allow time for the arrangement of appropriate resources for the member's care.
For post-acute care based services, which may include acute rehabilitation, skilled nursing facility stay, home care, durable medical equipment (DME), hospice care and transportation, the concurrent review nurse will facilitate prior approvals of medically necessary treatments if the member's benefit plan includes these services.
Readmission Policy
Concurrent Reviews (Effective June 1, 2018)
On a concurrent basis, any medically necessary readmission to the same facility/hospital/hospital system within 30 calendar days of a member's discharge for the same or similar diagnosis will be subject to a clinical review.
For facilities that bill under diagnosis-related groups (DRGs) or case rates:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.
For facilities that bill per diem (by the day):
- We will not make any changes or additions to the first hospital admission. The second admission will only be approved if we decide it's a separate event from the first admission.
- If the second admission is deemed a continuation of the first admission, it will be denied. A benefit denial will be sent with instructions about how to file a grievance (complaint).
Facilities may ask for the claim to be reconsidered (a peer-to-peer discussion) and reopened (Medicare only). If the facility sends additional clinical information, EmblemHealth will review the claim and decide if the second admission is related to the first.
Concurrent Reviews (In Effect August 1, 2017 to May 31, 2018)
On a concurrent basis, any medically necessary readmission to the same facility/hospital/hospital system within 14 calendar days of a member's discharge for the same or similar diagnosis will be subject to a clinical review.
For facilities that bill under diagnosis-related groups (DRGs) or case rates:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.
For facilities that bill per diem (by the day):
- We will not make any changes or additions to the first hospital admission. The second admission will only be approved if we decide it's a separate event from the first admission.
- If the second admission is deemed a continuation of the first admission, it will be denied. A benefit denial will be sent with instructions about how to file a grievance (complaint).
Facilities may ask for the claim to be reconsidered (a peer-to-peer discussion) and reopened (Medicare only). If the facility sends additional clinical information, EmblemHealth will review the claim and decide if the second admission is related to the first.
Concurrent Reviews (Retired July 31, 2017)
On a concurrent basis, any medically necessary readmission to the same facility within three calendar days following discharge from a medically necessary admission will be reviewed for the circumstances of the admission. The readmission will not be authorized for facility payment if due to one of the following:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.
Out-of-Network Facility Admissions
Admissions to out-of-network facilities in or out of the service area are monitored by telephonic review on a concurrent basis by the managing entity listed on the member's ID card. If the member is stable and needs ongoing care, a transfer may be initiated to facilitate the return of the member to care within the primary delivery system. If a member presents at a hospital emergency room and needs to be admitted, the hospital is required to notify the member's PCP immediately and to notify the member's managing entity listed on the back of the ID card within 24 hours or as soon as practicable thereafter. Following are ways to notify us of an emergency admission:
- Contracted hospitals may notify HIP and the managing entities, SOMOS, HealthCare Partners and Montefiore CMO, electronically of all admissions through the emergency room by signing in to www.emblemhealth.com for HIP, GHI HMO, CompreHealth EPO (Retired August 1, 2018) and Medicare HMO members. Benefits of electronic notifications are:
- 24/7 access.
- Automatic date/time-stamped receipt immediately sent back as proof of the notification.
- Immediate confirmation of member eligibility.
- Automatic and immediate routing for those cases managed by another entity on HIP's behalf; includes date/time stamp of notification to HIP.
- PCP name and contact information provided.
- Ability to follow status of inpatient case at www.emblemhealth.com. As soon as a notification is submitted, an inpatient case is created and assigned the same trace number referenced on the ER Admission Notification Receipt. For HIP-managed members, hospitals may use the trace number to find the inpatient case using the prior approval inquiry features. All cases appear in a pended status until all necessary information is received and concurrent review is performed.
- Contacted hospitals may notify HIP of emergency admissions for HIP, GHI HMO, CompreHealth EPO (Retired August 1, 2018) and Medicare HMO members by calling 1-866-447-9717 or faxing the notification to 1-866-215-2928.
- Contracted hospitals may notify Vytra by calling 1-888-288-9872.
- Contracted hospitals must notify GHI EPO/PPO and EmblemHealth EPO/PPO plans by calling 1-800-223-9870 or faxing the notification to 1-212-563-8391.
Note: Our plans do not require prior approval for an admission through the emergency room; rather, we require notification so that the case may be reviewed on a concurrent basis. No authorization number is required, and the managing entity will not issue an authorization and/or case number until the case has been reviewed for medical necessity.
If the facility fails to notify the managing entity of an admission through the emergency room, the managing entity will request medical records upon receipt of the claim and conduct a retrospective utilization review for medical necessity. Please see the Dispute Resolution chapters - Commercial/CHP, Medicaid, and Medicare. - for more details.
A member's PCP should respond to the hospital emergency room page within 30 minutes. If the hospital attempts to contact the member's PCP and does not make contact within 30 minutes, the hospital is instructed to contact the managing entity listed on the member's ID card for assistance in locating the PCP. The responding managing entity will obtain all relevant clinical information about the member.
Inpatient transfers between acute care hospitals/facilities
When a hospital or acute care facility does not have the services to ensure safe and/or quality care, it is the responsibility of the referring facility to contact the managing entity for all patient transfer requests by calling or faxing the applicable organization listed below:
Managing Entity/Members |
Phone |
Fax |
---|
EmblemHealth for HIP members |
866-447-9717 |
866-215-2928 |
EmblemHealth for Non-City of New York members and GHI retirees |
800-223-9870 |
212-563-8391 |
GHI PPO City of New York members and non-Medicare eligible retirees with GHI PPO benefits, contact Empire BCBS |
800-521-9574 |
800-241-5308 |
HealthCare Partners (HCP)-managed members |
800-877-7587 |
888-746-6433 |
Montefiore (CMO)-managed members |
888-666-8326 |
n/a |
SOMOS |
844-990-0255 |
877-590-8003 |
When contacting us, please have the following information available:
- Member ID number
- Member name
- Name of hospital/acute care facility accepting patient
- Name of physician accepting patient (from accepting hospital)
- Name of physician transferring care (from transferring hospital)
- Name of referring hospital/acute care facility
- Diagnosis
- Reason for transfer
For EmblemHealth-managed HIP and GHI members, a concurrent review nurse will review and refer all requests to an EmblemHealth Medical Director for a determination based on the clinical urgency of the specific situation. A decision will be made within one (1) business day, or in the case of a weekend on the same day of receiving all requested information. If the transfer request is approved, the concurrent review nurse will contact the transferring facility and issue a case number for the transfer.
It is the accepting hospital/acute care facility’s responsibility to confirm the transfer is authorized and to obtain the case number from the transferring facility. To receive payment, the accepting facility must include the case number on all associated claim submissions.
If the request for the transfer is denied, refer to the applicable Dispute Resolution chapter – Commercial/CHP, Medicaid, and Medicare..
Concurrent Review
Once a member is admitted to a facility, the applicable Managing Entity will reach out to the facility for clinical information to evaluate the on-going medical necessity of the in-patient stay. Facilities are allowed 24 hours to provide the requested information. Decisions will be made based upon available information. EmblemHealth follows industry standard medical care guidelines (found at www.MCG.com) to determine the appropriate review frequency. On-going requests for clinical information will be made consistent with the goal length of stay expected for the admission. Facilities should expect to receive requests for additional information approximately 24 hours before the expected goal length of stay has expired. If the requested information is not provided, the day will be denied with a provider/facility denial. The member may not be billed for this day.
Concurrent Review Status Report
The Concurrent Review Status Report (see an example at the end of this chapter) will be posted to our secure website at www.emblemhealth.com, Monday through Friday (excluding holidays), twice a day at around 10 am and 5 pm. This report lists each admitted member and whether the current day is approved, denied or pending further information. Pending information means we require additional information to make a determination. If the requested information is not provided, the day will be denied with a provider/facility denial. The member may not be billed for this day.
Emergency Services for Out-of-Area
Medicaid and Commercial members are covered for emergency care in all 50 United States, Canada, Puerto Rico and the United States Territories of the Virgin Islands, Guam, American Samoa and the Northern Marianna Islands. Medicare members are covered for emergency care worldwide. In an emergency that meets this definition, members in one of these areas can go to the nearest emergency room or call 911.
In-Hospital Services
All in-hospital services and ancillary support should be provided by network physicians.
See the Use of Out-of-Network Providers subsection in the Care Management chapter.
Medicare Outpatient Observation Notice MOON
On August 6, 2015, Congress enacted the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which requires all hospitals and critical access hospitals (CAHs) to provide written notification and an oral explanation of such notification to individuals receiving observation services as outpatients for more than 24 hours. A standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611 was developed to inform all Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH.
In accordance with the statute, the notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services. Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged, or admitted.
All hospitals and CAHs are required to provide this statutorily required notification no later than March 8, 2017. The notice and accompanying instructions are available at:
https://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html
Discharge Planning
The discharge planning process should begin as soon as possible to allow time for the arrangement of appropriate resources for the member's care.
For post-acute care based services, which may include acute rehabilitation, skilled nursing facility stay, home care, durable medical equipment (DME), hospice care and transportation, the concurrent review nurse will facilitate prior approvals of medically necessary treatments if the member's benefit plan includes these services.
Readmission Policy
Concurrent Reviews (Effective June 1, 2018)
On a concurrent basis, any medically necessary readmission to the same facility/hospital/hospital system within 30 calendar days of a member's discharge for the same or similar diagnosis will be subject to a clinical review.
For facilities that bill under diagnosis-related groups (DRGs) or case rates:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.
For facilities that bill per diem (by the day):
- We will not make any changes or additions to the first hospital admission. The second admission will only be approved if we decide it's a separate event from the first admission.
- If the second admission is deemed a continuation of the first admission, it will be denied. A benefit denial will be sent with instructions about how to file a grievance (complaint).
Facilities may ask for the claim to be reconsidered (a peer-to-peer discussion) and reopened (Medicare only). If the facility sends additional clinical information, EmblemHealth will review the claim and decide if the second admission is related to the first.
Concurrent Reviews (In Effect August 1, 2017 to May 31, 2018)
On a concurrent basis, any medically necessary readmission to the same facility/hospital/hospital system within 14 calendar days of a member's discharge for the same or similar diagnosis will be subject to a clinical review.
For facilities that bill under diagnosis-related groups (DRGs) or case rates:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.
For facilities that bill per diem (by the day):
- We will not make any changes or additions to the first hospital admission. The second admission will only be approved if we decide it's a separate event from the first admission.
- If the second admission is deemed a continuation of the first admission, it will be denied. A benefit denial will be sent with instructions about how to file a grievance (complaint).
Facilities may ask for the claim to be reconsidered (a peer-to-peer discussion) and reopened (Medicare only). If the facility sends additional clinical information, EmblemHealth will review the claim and decide if the second admission is related to the first.
Concurrent Reviews (Retired July 31, 2017)
On a concurrent basis, any medically necessary readmission to the same facility within three calendar days following discharge from a medically necessary admission will be reviewed for the circumstances of the admission. The readmission will not be authorized for facility payment if due to one of the following:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The admission will be denied and a benefit denial will be issued. The facility will be advised of its grievance rights. In the event that a readmission case requires additional clinical information and it is provided by the facility, the review determines if the circumstances of the second admission are related to the first admission.
Out-of-Network Facility Admissions
Admissions to out-of-network facilities in or out of the service area are monitored by telephonic review on a concurrent basis by the managing entity listed on the member's ID card. If the member is stable and needs ongoing care, a transfer may be initiated to facilitate the return of the member to care within the primary delivery system.