Independent from prior authorization, notification by the facility is required for inpatient admissions on the day of admission for urgent/emergent, scheduled/ elective, medical, surgical, out-of-area, hospice and obstetrical services.
Hospitals, rehabilitation facilities and skilled nursing facilities are required to notify us daily of all admissions, changes in inpatient status and discharge dates.
Definition of Facility-Based Outpatient Surgery (CA, OR, WA and NV)
Facility-Based Outpatient Surgery services are defined using CMS Guidelines, CPT/HCPCS coding conventions, as well as clinical and/or proprietary standards. The following denotes services considered Facility-Based Outpatient Surgery services under this definition:
- A procedure with an ASC grouping assigned as of 2007;
- A procedure with a global period of 90 days (according to the care provider fee schedule);
- Core needle biopsies;
- Unlisted or new codes may be considered surgery in the following situations:
- Unlisted or new code is related to other codes in the same APC group that had an ASC assigned as of 2007, it is considered Facility-Based Outpatient Surgery.
- A procedure with surgical risk or anesthetic risk as determined by clinical review.
Facilities are responsible for for notifying us of all member inpatient admissions including:
- Planned/elective admissions for acute care
- Unplanned admissions for acute care
- SNF admissions
- Admissions following outpatient surgery
- Admissions following observation
- Newborns admitted to Neonatal Intensive Care Unit (NICU)
- Newborns who remain hospitalized after the mother is discharged (notice required within 24 hours of the mother’s discharge)
We must receive the admission notification within 24 hours after actual weekday admission (or by 5 p.m. local time on the next business day if 24 hour notification would require notification on a weekend or holiday). For weekend and holiday admissions, we must receive the notification by 5 p.m. local time on the next business day.
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 participation agreement with UnitedHealthcare.
Admission notifications must contain the following details regarding the admission:
- Member name, health care ID number, and date of birth
- Facility name and TIN or NPI
- Admitting/attending physician name and TIN or NPI
- Description for admitting diagnosis or ICD-10-CM diagnosis code
- Actual admission date
- Primary medical group/IPA
For emergency admissions where a member is unstable and not capable of providing coverage information, the facility should notify us by phone or fax 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:
- Census report for all our members;
- Discharge report; and
- Face sheets to report outpatient surgeries and SNF admissions; or
- Inpatient Admission Fax Sheet to report “no UnitedHealthcare West admissions” for that day.
The census report or face sheets must include the following information:
- Primary medical group/IPA
- Admit date
- Member name (first and last) and date of birth
- Bed type/accommodation status/level of care (LOC)
- Expected length of stay (LOS)
- Admitting physician
- Admitting diagnosis (ICD-10-CM)
- Procedure/surgery (CPT Code) or reason for admission
- Attending physician
- Policy number/member health care ID number
- Other insurance
- Authorization number (if available)
- Discharge report, including member demographic information, discharge date and disposition
Coordination of Care
Facilities are required to assist in the coordination of a member’s care by:
- Working with the member’s PCP;
- Notifying the PCP of any admissions; and
- Providing the PCP with discharge summaries.
After Hour Admissions/SNF Transfers
- For admissions or transfers after hours or on weekends, the member should be admitted to the appropriate facility at the appropriate level of care. Authorization must be obtained on the next business day.
- Transfers/admissions to SNFs can be admitted directly from the emergency room or home to a SNF.
- A referral/transfer to a non-network facility requires prior authorization. However, in the case of an emergency, a non-participating hospital may be used without prior authorization.
- After initial emergency treatment and stabilization, we may request that a member be transferred to a network hospital, when medically appropriate.
- If a PCP directs a member to a non-network hospital for non-emergent care without prior authorization, the PCP may be held responsible.
Consultation with Providers During Inpatient Stays
Authorization is not required for a consultation with a participating network 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. Concurrent review is performed by phone, as well as onsite at designated facilities, by clinical staff. 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 patient’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 approval. If approved, 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.
Medical Observation Status
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 and typically lasts less than 48 hours. 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.
Emergency and/or Direct Urgent Admissions (Commercial Plans)
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.
Skilled Nursing Facilities
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:
- Assessment and documentation of the member’s needs as compared to those upon admission, including the member’s functional status and anticipated discharge disposition, if other than a discharge to home;
- Development of a discharge plan, including evaluation of the member’s financial and social service needs and potential need for post-hospital services, such as home health, DME, and/or placement in a SNF or custodial care facility;
- Approved authorizations for necessary post-discharge plan, as required by us;
- Organization, communication and execution of the discharge plan;
- Evaluation of the effectiveness of the discharge plan;
- Referrals to population-based disease management and case management programs, as indicated.
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.
Retrospective Review (Medical Claim Review)
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:
- High-dollar claims;
- Claims without required authorization;
- Claims for unlisted procedures;
- Trauma claims;
- Claims for implants that are not identified or inconsistent with the UnitedHealthcare West’s Implant Guidelines;
- Claim check or modifier edits based on our claim payment software;
- Foreign country claims; and
- Claims with LOS or LOC mismatch.
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.
Minimum Content Denials, Delays, or Modification Requests
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:
- The specific service(s) denied, delayed in delivery, modified or partially approved;
- The specific reference to the benefit plan provisions to support the decision;
- The reason the service is being denied, delayed in delivery, modified, or partially approved, including:
- Clear and concise explanation of the reasons for the decision in sufficient detail, using an easily understandable summary of the criteria, so that all parties can understand the rationale behind the decision;
- Description of the criteria or guidelines used, and/or reference to the benefit provision, protocol or other similar criterion on which the decision was based;
- Clinical reasons for decisions regarding medical necessity; and
- Contractual rationale for benefit denials.
- Notification that the member can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the denial decision was based, upon request;
- Notification that the member’s physician can request a peer-to-peer review;
- Alternative treatment options offered, if applicable;
- Description of any additional material or information necessary from the member to complete the request, and why that information is necessary;
- Description of grievance rights and an explanation of the appeals and grievances processes, including:
- Information regarding the member’s right to appoint a representative to file an appeal on the member’s behalf;
- The member’s right to submit written comments, documents or other additional relevant information;
- Information notifying the member and their treating care provider of the right to an expedited appeal for time- sensitive situations (not applicable to retrospective review);
- Information regarding the member’s right to file a grievance or appeal with the applicable state regulatory agency, including information regarding the independent medical review process, as applicable;
- Information that the member may bring civil action, under Section 502(a) of the Employee Retirement Income Security Act (ERISA), if applicable (Commercial products);
- For the treating care provider, the name and direct phone number of the health care professional responsible for the decision.