The utilization 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, preauthorization of facility admissions, concurrent management in the hospital, use of alternate care facilities and post-discharge follow-up.
All in-hospital services and ancillary support should be provided by network physicians. See the Use of Out-of-Network Providers subsection in this chapter.
Elective Inpatient Procedures - Admitting Physicians
The admitting network physician is required to obtain preauthorization for elective inpatient procedures at least ten (10) business days in advance of the desired hospital admission date. This allows us enough 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 preauthorization status of an admission by signing in to emblemhealth.com/providers and using the Search Preauthorization drop-down under the Preauthorization tab or calling 866-447-9717.
If the admitting physician is out-of-network, the member is responsible for contacting EmblemHealth or the Managing Entity for preauthorization. For more information, see the Who to Contact for Preauthorization section of the Directory chapter.
Elective Admission Procedures - Hospitals and Facilities (Including Acute, Inpatient Rehabilitation and Psychiatric Facilities)
The admitting facility (including hospitals) must confirm there is a preauthorization on file for all elective, non-emergent admissions and ambulatory procedures.
In the event the facility is aware the planned admission/procedure date has changed within a 90-day period, the facility should notify EmblemHealth or the Managing Entity of the new date(s) and ask to modify the date(s) of the preauthorization. An anticipated care report is faxed daily to the facility listing the approved days/services. If no services are approved for the facility, a report is not sent.
The facility must ask to see the member's ID card upon admission. The ID card provides line of business information as well as the Managing Entity’s information for requesting preauthorization and submitting claims. The facility must verify member benefit and eligibility information by signing in to emblemhealth.com/providers and using the Eligibility drop-down under the Member Management tab.
Claims are denied if no preauthorization has been issued where one is required. For information on denial determinations, see the applicable Dispute Resolution chapters – Commercial/CHP, Medicaid or Medicare.
If a facility fails to obtain preauthorization for an elective inpatient hospital admission, claims will not be paid until medical necessity is established. Facilities will have 45 days to submit clinical information to EmblemHealth or the Managing Entity to support the elective inpatient services. A clinical determination will be made within 15 days of receipt of the clinical information, but no later than 60 days from the request. As usual, the facility may file a utilization review appeal for any denial.
Furthermore, New York State allows health plans to impose administrative denials if there is a systemic and repeated failure of any facility to obtain preauthorization for an elective inpatient admission.
Should the facility feel an overnight stay is warranted for an outpatient service, EmblemHealth or the Managing Entity must re-evaluate the admission for medical necessity. All necessary information must be submitted 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 the Managing Entity listed on the back of the ID card within 24 hours or as soon as possible thereafter. Here are ways to notify us of an emergency admission:
- Contracted hospitals may notify EmblemHealth electronically of all admissions through the emergency room by signing in to emblemhealth.com/providers and using the Create ER Notification drop-down under the More tab.. 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 of cases managed by another entity on EmblemHealth’s behalf; includes date/time stamp of notification to EmblemHealth.
- PCP name and contact information provided.
- Ability to follow status of inpatient case when signing in to emblemhealth.com/providers and using the Concurrent Review Status Report drop-down under the Preauthorization tab.. 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 preauthorization inquiry features. All cases appear in a pended status until all necessary information is received and concurrent review is performed.
- Contracted hospitals may notify EmblemHealth of emergency admissions for HIP and Medicare HMO members by calling 866-447-9717 or faxing the notification to 866-215-2928.
- Contracted hospitals may notify EmblemHealth for GHI EPO/PPO and EmblemHealth EPO/PPO plans by calling 800-223-9870 or faxing the notification to 212-563-8391.
Note: Our benefit plans do not require preauthorization for an admission through the emergency room; rather, we require notification, so the case may be reviewed on a concurrent basis. No authorization number is required, and the Managing Entity does not issue an authorization and/or case number until the case has been reviewed for medical necessity.
The responding Managing Entity obtains all relevant clinical information about the member. If the facility fails to notify the Managing Entity of an admission through the emergency room, the Managing Entity requests medical records upon receipt of the claim and conducts a retrospective utilization review for medical necessity. For more details, see the applicable Dispute Resolution chapters – Commercial/CHP, Medicaid or Medicare.
A member's PCP should respond to the hospital emergency room notification 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.
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.
Inpatient Transfers Between Hospitals/Acute Care 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:
When contacting us, 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
- Reason for transfer
For EmblemHealth-managed HIP and GHI members, a concurrent review nurse reviews and refers all requests to an EmblemHealth Medical Director for a determination based on the clinical urgency of the specific situation. A decision is 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 contacts the transferring facility and issues 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 or Medicare.
Concurrent Review (Non-DRG Inpatient Stays)
Once a member is admitted to a facility, the applicable Managing Entity reaches 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 are made based on available information. EmblemHealth follows industry standard medical care guidelines (found at MCG.com) to determine the appropriate review frequency. Ongoing requests for clinical information are 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 (excluding weekends and holidays). If the requested information is not provided, the day is denied. 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 is posted on our secure website at emblemhealth.com/providers under the Preauthorization tab and Concurrent Review Status Report drop-down, Monday through Friday (excluding holidays), twice a day at between 10 a.m. and 5 p.m. 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 is denied. 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.
Post-Service Review (In the event the participating hospital does not notify on admission)
Commercial/Child Health Plus
When a claim is submitted for an admission through the emergency department without having received timely notification, records are requested from the facility for an initial retrospective clinical review by the Post-Service Review department. The facility is given 30 days to submit the records. If records are received within 45 calendar days from receipt of request, they are reviewed for medical necessity. 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 are included in the communication.
When a claim is submitted for an admission through the emergency department without having received timely notification, records are requested from the facility for an initial retrospective clinical review by the Post-Service Review department. The facility is given 30 days to submit the records. A clinical determination is made within 30 calendar days from receipt of request and 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 are included in the communication.
Failure by EmblemHealth or the utilization review agent to make a determination within the required time frames is deemed adversely determined and subject to appeal.
Retrospective Utilization Review
Initial review, post-discharge, of a case where the claim was denied for no preauthorization, or for which no concurrent review was performed:
- Whoever is responsible for managing the case (i.e., the Managing Entity) performs the facility retrospective utilization review.
- The Managing Entity renders 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.
The discharge planning process should begin as soon as possible to allow time to arrange appropriate resources for the member's care. Post-acute care-based services may include acute rehabilitation, skilled nursing facility stay, home care, durable medical equipment (DME), hospice care and transportation. The facility must request preauthorizations of medically necessary treatments from the Managing Entity, if the member's benefit plan includes these services.
On a concurrent basis, any readmission to the same facility/hospital /hospital system within 30 calendar days of a member's discharge for the same or similar diagnosis is subject to a clinical review. The readmission is denied, and a benefit denial is issued if the readmission is determined to be a:
- Relapse of conditions noted on the first admission
- Complications of treatment or diagnostic investigations
- Insufficient stabilization of patient’s condition prior to discharge
The facility is advised of its grievance rights. In the event 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.
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 reviews the claim and decides if the second admission is related to the first.
Medicare Outpatient Observation Notice MOON
The Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, 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. The standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611 informs all Medicare beneficiaries when they are an outpatient receiving observation services and are not an inpatient of the hospital or CAH.
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. Instructions are available at: