Except as otherwise provided, NHP requires prior authorization prior to these admissions:
All hospital admissions*
Inpatient rehabilitation facility
Skilled nursing facility
Long term acute care facility
Special care unit
You must provide clinical information to support the medical necessity of the admission and/or observation stay, by the next business day following the admission. Final determinations are made by a medical director, as appropriate.
Drug prior authorization
To promote appropriate utilization, NHP requires prior authorization for certain medications dispensed through the pharmacy (prescription drug benefit) and/or incident to a physician’s service (medical benefit). If the medication is to be dispensed by a participating pharmacy, the health care provider must provide clinical information to OptumRx. Prior authorization does not guarantee coverage.
For a full description of our clinical programs on medications dispensed through the outpatient pharmacy benefit, refer to uhcprovider.com. To determine medications available through the pharmacy benefit, go to uhcprovider.com/priorauth > Clinical Pharmacy and Specialty Drugs.
Chemotherapeutic agents administered through the medical benefit require prior authorization. For the most current and complete list, go to uhcprovider.com/priorauth > Oncology.
The continued stay for all inpatient admissions must be certified through the concurrent review process. Upon request, you must submit to NHP, or its delegated entities, sufficient clinical information to:
Certify the continued stay.
Allow the review of the member’s medical status during an inpatient stay.
Extend the member’s stay.
Coordinate the discharge plan.
Determine medical necessity at an appropriate level of care.
Perform quality assurance screening.
All discharge planning and cases requiring comprehensive services for catastrophic or chronic conditions are coordinated through NHP Case Management. This includes OB care. If the diagnosis or treatment of a member is delayed secondary to the inability of the facility to provide a needed service, payment for these days is denied. This includes, but is not limited to, the unavailability of diagnostic and/or surgical services on weekends and holidays, delays in the interpretation of diagnostic testing, delays in obtaining requested consultations and late rounding by the admitting physician.
Reimbursement for continued stay that does not meet NHP medical necessity criteria is denied. The member may not be billed for these services unless they have signed a waiver of liability or the services are denied as non-covered services. The member is held harmless in these proceedings.
*Admissions from the emergency room, to the ICU/CCU, or admission for emergency surgery must be Post-certified by the next business day following admission.