Clinical Process Definitions
Some services may be subject to prior authorization and/or ongoing medical necessity reviews.
Acute Hospital Day
An acute hospital day (AHD) is any day when the severity of illness (clinical instability) and/or the intensity of service are sufficiently high and care cannot reasonably be provided safely in another setting.
Alternative Level of Care (ALC)*
We will determine that an inpatient ALC applies in any of the following scenarios:
- An acute clinical situation has stabilized.
- The intensity of services required can be provided at less than an acute level of care.
- An identified skilled nursing and/or skilled rehabilitative service is medically indicated.
- ALC is prescribed by the member’s care provider or other health care professional.
- Inpatient ALC must meet the following criteria:**
- The skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists are required; and
- Such services must be provided directly by or under the general supervision of those skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.
*ALC only applies if the facility has a contracted rate.
** Inpatient ALC must meet clinical criteria per clinical guidelines. Failure to satisfy these criteria can result in denial of coverage.
New technology refers to a service, product, device, or drug that is new to our service area or region. Any new technology must be reviewed and approved for coverage by the Medical Technology Assessment Committee or the Clinical Technology Assessment Committee for Behavioral Health technologies.
Potentially Avoidable Days
A potentially avoidable day (PAD) arises in the course of an inpatient stay when, for reasons not related to medical necessity, a delay in rendering a necessary service results in prolonging the hospital stay. PADs must be followed by a medically necessary service.
There are several types of PADs:
- Approved potentially avoidable day (AOPAD): We caused delay in service; the day will be payable.
- Approved care provider or other health care professional potentially avoidable day (APPAD): The care provider or other health care professional caused delay in service; the day will be payable.
- Approved mixed potentially avoidable day (AMPAD): A delay due to mixed causes not solely attributable to us, the care provider, other health care professional, or the hospital; the day will be payable.
- Denied hospital potentially avoidable day (DHPAD): The hospital caused the delay in service; DHPAD is a non-certification code, and the day is not payable. We will not reverse any certified day unless the decision to certify was based on erroneous information supplied by the care provider or other health care professional, or a potentially avoidable day was identified.
When a member is readmitted to the hospital for the same clinical condition or diagnosis within 30 days of discharge, the second hospital admission will not be reimbursed when any of the following conditions apply:
- The member was admitted for surgery, but surgery was canceled due to an operating room scheduling problem.
- A particular surgical team was not available during the first admission.
- There was a delay in obtaining a specific piece of equipment.
- A pregnant woman was readmitted within 24 hours and delivered.
- The member was admitted for elective treatment for a particular condition, but the treatment for that condition was not provided during the admission because another condition that could have been detected and corrected on an outpatient basis prior to the admission made the treatment medically inappropriate.
In any of the situations noted above, the hospital cannot bill the member for any portion of the covered services not paid for by us.
Diagnosis-Related Group (DRG) Hospitals
DRG is a statistical system of classifying an inpatient stay into groups of specific procedures or treatments. When a hospital contracts for a full DRG, we will reimburse the hospital a specific amount (determined by the contract) based on the billed DRG rather than paying a per diem or daily rate (DRG facility). A DRG is determined after the member has been discharged from the hospital.
When admission information is received through our website, we will consider this to be notification only; first day approval will not be granted to hospitals with a DRG contract. When we receive notification of an admission to a hospital with a DRG contract, our case manager will review the admission for appropriateness. If the case manager cannot make a determination based on the admitting diagnosis, the case manager will request an initial review to determine whether the admission is medically necessary. The hospital is required to provide admission notification.
Prepayment DRG Validation Program
We may request a DRG hospital to send the inpatient medical record before claim payment so we may validate the submitted codes. After review of all available medical information, the claim will be paid based on substantiated codes following review of the medical record.
See the Claims Recovery, Appeals, Disputes and Grievances section of this supplement for Appeal Rights.
Hospital records may be requested to validate ICD-10-CM or its successor codes and/or revenue codes billed by participating facilities for inpatient hospital claims. If the billed ICD-10-CM codes (or successor codes) or revenue codes are not substantiated, the claim will be paid only with the validated codes.
A disposition determination is a technical term describing a process of care determination that results in payment as agreed at specific contracted rates, and is designed to eliminate certain areas of contention among participating parties and allow processing of claims. Specific instances where a disposition determination may apply:
- Delay in hospital stay
- APPAD/AMPAD when so contracted
- ALC determinations when so contracted, unless there is a separate ALC rate
- Discharge delays that prolong the hospital stay under a case rate
Late and No Notification
Late notification is defined as notification of a hospital admission after the contracted 48-hour notification period and prior to discharge. No notification is defined as failure to notify us of a member’s admission to a hospital after discharge, up to and including at the time of submitting the claim.
Mental Health and Substance Use Services
The behavioral health department specializes in the administration of mental health and substance use benefits. The department consists of a medical director who is licensed in psychiatry, facility care advocates (licensed RNs and licensed/certified social workers) and intake staff who collectively handle certification, referrals and case management for our members.
We encourage coordination of care between our participating behavioral health clinicians and primary care providers as the best way to achieve effective and appropriate treatment. For this purpose, we developed a Release of Information (ROI) Form that is designed to facilitate member consent and to share information with the PCP in the presence of their behavioral health clinician. See the How to Contact Oxford Commercial section for telephone numbers.
Clinical Definitions and Guidelines
The behavioral health department uses the Optum Level of Care Guidelines when determining the medical necessity of inpatient psychiatric, partial hospitalization substance use treatment and rehabilitation, and outpatient mental health treatment. For a complete list of programs and detailed information on the level of care guidelines visit the Optum network website at providerexpress.com.
Inpatient Mental Health
Inpatient (or acute) care for a mental health condition is indicated when it involves a sudden and quickly developing clinical situation characterized by a high level of distress and uncertainty of outcome without intervention.
Partial Hospitalization - Mental Health
Partial hospitalization for mental health treatment involves day treatment of a mental health condition at a hospital or ancillary facility with the following criteria:
- The primary diagnosis is psychiatric.
- The facility is licensed and accredited to provide such services.
- The duration of each treatment is four or more hours per day.
Residential treatment services are provided in a facility or a freestanding residential treatment center that provides overnight mental health services for members who do not require acute inpatient care but who do require 24- hour structure.
Outpatient Mental Health
Psychotherapeutic approaches to treatment of mental health conditions, including methods from different theoretical orientations (e.g., behavioral, cognitive, and interpersonal) may be administered to an individual, family or group on an outpatient basis.
Inpatient detoxification is defined as the treatment of substance dependence to treat a life-threatening withdrawal syndrome, provided on an inpatient basis.
Outpatient Substance Use Rehabilitation
Outpatient substance use rehabilitation is defined as the treatment of a substance use disorder including dependence at an accredited, licensed substance use treatment facility.