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Chapter 15: SNF IRF LTAC
This program applies to post-acute care (PAC) services and direct admissions from the community for EmblemHealth members (see the section below for Excluded Members). EmblemHealth manages most PAC preauthorizations and utilization management of requested community referral services.
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 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 by signing in to our secure portal at emblemhealth.com/providers and using the Eligibility drop-down under the Member Management tab.
The following members are excluded from the EmblemHealth PAC preauthorization process:
- City of New York Employees with EmblemHealth Plan, Inc. (formerly GHI) benefit plans – requests should be made to Empire BCBS (refer to Who to Contact for Preauthorizations)
- Members whose ID card indicates a primary care provider (PCP) from one of the following Managing Entities:
- HealthCare Partners (HCP)
Excluded members are medically managed by the assigned Managing Entity in the same way as they are for other services. To determine the Managing Entity, check the member’s ID card or eligibility information by signing in to the secure portal at emblemhealth.com/providers and using the Eligibility drop-down under the Member Management tab. 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. See the Utilization and Care Management chapter of the Provider Manual for applicable rules and preauthorization processes.
Denial of Preauthorization
Cases that do not meet medical necessity on initial nurse review are sent to a physician for second-level review and determination. If the EmblemHealth physician makes an adverse determination, the requesting facility is contacted.
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 physician for second-level review and determination. If the EmblemHealth physician makes an adverse determination, the requesting facility is contacted.
SNF Date Extensions (concurrent review requests) for Medicare Members: 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.
If a member appeals the end-of-stay decision through a Medicare-contracted Quality Improvement Organization (QIO), the SNF is responsible for sending the medical records to the QIO by the time indicated on the request for records. QIO is open seven (7) days a week to take appeal information.
Refer to the applicable Dispute Resolution chapters for Commercial/CHP plans, Medicaid plans, and Medicare plans.