eviCore healthcare (eviCore) handles prior approval requests for post-acute care 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 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 EmblemHealth Members via the eviCore web portal or by calling eviCore at 866-417-2345, option 3 for EmblemHealth, or option 5, then 2 for PAC.
eviCore only manages members in Skilled Nursing, Inpatient Rehab, and Long-Term Care for 90 days. Thereafter, please contact EmblemHealth at 888-447-2884 to address ongoing inpatient days.
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 EmblemHealth Members via the eviCore web portal or by calling eviCore at 866-417-2345, option 3 for EmblemHealth, 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 EmblemHealth 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 emblemhealth.com/Providers. The following sections describe the information you will need to submit to eviCore and the processes for submitting prior approval requests.
The requesting provider should be prepared to submit:
How to Request Prior Approval For SNF/IRF/LTAC
||Methods to Submit Prior Approval Requests
||eviCore offers two convenient methods to request prior approval, depending on the Program:
1. Call 866-417-2345, option 3 for EmblemHealth 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.
||Call (800) 877-7587 or fax your request to (888) 746-6433.
||Call (888) 666-8326.
||Inpatient Rehab Facility
||Long Term Acute Care
||3 calendar days
||5 calendar days
||5 calendar days
||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 EmblemHealth 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
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.
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.
Permanent Placement Process for Medicaid Members
If a Medicaid member needs long-term residential care, the facility is required to request increased coverage from the Local Department of Social Services (LDSS) within 48 hours of a change in a member’s status via submission of the DOH-3559 (or equivalent).
The facility must also submit a completed Notice of Permanent Placement Medicaid Managed Care (MAP Form) within 60 days of the change in status to the LDSS. The facility must notify EmblemHealth of the change in status. If requested, the facility must submit a copy of the MAP form to EmblemHealth for approval prior to facility’s submission of the MAP form to the LDSS.
Payment for residential care is contingent upon the LDSS’ official designation of the member as a Permanent Placement Member.
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.
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.