Independent from prior authorization, notification by the facility is required for inpatient admissions on the day of admission, even if an advanced notification was provided prior to the actual admission date.
Hospitals, rehabilitation facilities and skilled nursing facilities (SNFs) are required to notify us daily of all admissions, changes in inpatient status and discharge dates.
Facilities are responsible for admission notification, even if advance notification was provided by the physician and coverage approval is on file.
Facility-Based Outpatient Surgery services are defined using CMS Guidelines, CPT/HCPCS coding conventions, and clinical and/or proprietary standards. The following denotes services considered Facility-Based Outpatient Surgery services under this definition:
Facilities are responsible for notifying us of all member inpatient admissions including:
Receipt of an admission notification does not guarantee or authorize payment. Payment of covered services is contingent upon coverage within the member’s benefit plan, the facility being eligible for payment, compliance with claim processing requirements, and the facility’s Agreement with UnitedHealthcare.
Admission notifications must contain the following details regarding the admission:
For emergency admissions where a member is unstable and not capable of providing coverage information, the facility should notify us online, by EDI or by phone within 24 hours (or the next business day, for weekend or holiday admissions) from the time the information is known and communicate the extenuating circumstances.
The following reports must be faxed daily to our Clinical Information Department:
The census report or face sheets must include the following information:
Facilities are required to assist in the coordination of a member’s care by:
Authorization is not required for a consultation with a participating care provider during an inpatient stay. However, consultation with a non-network care provider requires prior authorization.
We conduct concurrent review on all admissions from the day of admission through the day of discharge. Clinical staff perform concurrent reviews by phone, as well as onsite at designated facilities. We have established procedures for onsite concurrent review which include: (a) guidelines for identification of our staff at the facility; (b) processes for scheduling onsite reviews in advance; and (c) staff requirements to follow facility rules. If the clinical reviewer determines that the member may be treated at a lower level of care or in an alternative treatment setting, we discuss the case with the hospital case manager and the admitting physician. If a discrepancy occurs, our medical director or designee discusses the case with the admitting physician.
Variance days are days we determine inpatient care coordination and provision of diagnostic services are not medically necessary or are not provided in a timely manner contributing to delays in care. We adjust reimbursement accordingly. Our concurrent review staff attempts to minimize variance days by working with the attending physicians and hospital staff. If a variance is noted in the member’s acute care process, our concurrent review staff discusses the variance with the hospital’s medical management/case management representative. If the variance exists after the discussion, our concurrent review staff documents the variance in our utilization records and submits to a UnitedHealthcare concurrent review manager for review. If upheld, the variance is entered into our database as a denial of reimbursement for the variance time period. We mail a letter to the facility stating the variance type and time period. The facility may appeal the variances in writing.
Our medical director will review the appeal and render a decision to overturn or uphold the decision.
We authorize hospital observation status when medically appropriate. Hospital observation is generally designed to evaluate a member’s medical condition and determine the need for actual admission, or to stabilize a member’s condition. For MA members, we also follow any applicable CMS guidelines to determine whether observation services are medically appropriate. Typical cases, when observation status is used, include rule-out diagnoses and medical conditions that respond quickly to care. Members under observation status may later convert to an inpatient admission if medically necessary.
If a hospital does not receive authorization from us within one hour of the initial call requesting authorization, the emergent and/ or urgent services prompting the admission are assumed to be authorized and should be documented as such to us until we direct or arrange care for the member. Once we become involved with managing or directing the member’s care, all services provided must be authorized by us.
Before transfer/admit to a SNF, we must approve the member’s treatment plan. The member’s network physician must perform the initial physical exam and complete a written report within 48 hours of a member’s admission to the SNF. We perform an initial review and subsequent reviews as we deem necessary. Federal and state regulations require that members at SNFs be seen by a physician at least once every 30 calendar days.
The initial evaluation for discharge planning begins at the time of notification of inpatient admission. A comprehensive discharge plan includes, but is not limited to, the following:
For after-hours or weekend discharges requiring home health and/or DME, facility should arrange the care and obtain authorization on the next business day.
Medical claim review, also known as medical cost review, medical bill review and/or retrospective review, is the examination of the medical documentation and/or billing detail after a service has been provided. Medical claim review is performed to provide a fair and consistent means to retrospectively review medical claims and make sure medical necessity criteria are met, confirm appropriate level of care and length of stay, correct payer source, and identify appropriate potential unbundling and/or duplicate billing occurrences.
The review includes an examination of all appropriate claims and/or medical records against accepted billing practices and clinical guidelines as defined by entities such as CMS, AMA, CPT coding and MCGTM Care Guidelines depending on the type of claims submitted.
Claims that meet any of the following criteria are reviewed before the claim is paid:
To help ensure timely review and payment determinations, you must respond to requests for all appropriate medical records within seven calendar days from receipt of the request, unless otherwise indicated in your Agreement.
We may review specific claims based on pre-established retrospective criteria to make sure acceptable billing practices are applied.
For hospital care providers, we may reduce the payable dollars if line item charges have been incorrectly unbundled from room and board charges.
If we deny, delay delivery, or modify a request for authorization for health care services, our written or electronic notices will, at a minimum, include the following: