Some services may be subject to prior authorization and/or ongoing medical necessity reviews.
An AHD is any day when the severity of illness (clinical instability) and/or the intensity of service are sufficiently high, and care may not reasonably be provided safely in another setting.
We determine that an inpatient ALC applies in any of the following scenarios:
› 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.
› 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 achieve the medically desired result.
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.
A 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:
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:
In any of these situations, the hospital may not bill the member for any portion of the covered services not paid for by us.
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 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 consider this to be notification only. First-day approval is granted to hospitals with a DRG contract. When we receive notification of an admission to a hospital with a DRG contract, our case manager reviews the admission for appropriateness. If the case manager cannot make a determination based on the admitting diagnosis, the case manager requests an initial review to determine whether the admission is medically necessary. The hospital is required to provide admission notification.
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 is 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 is paid only with the validated codes.
*Inpatient ALC must meet clinical criteria per clinical guidelines. Failure to satisfy these criteria may result in denial of coverage.
A disposition determination is a technical term describing a process of care determination that results in payment as agreed at specific contracted rates. It helps eliminate certain areas of contention among participating parties and allows processing of claims. Specific instances where a disposition determination may apply:
Late notification is defined as notification of a hospital admission after the contracted 48-hour notification period and before 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.
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.
The behavioral health department uses the Optum Lev.el 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 (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 for mental health treatment involves day treatment of a mental health condition at a hospital or ancillary facility with the following criteria:
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 require 24-hour structure.
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 the treatment of substance dependence to treat a life-threatening withdrawal syndrome, provided on an inpatient basis.
Outpatient substance use rehabilitation is the treatment of a substance use disorder including dependence at an accredited, licensed substance use treatment facility.