When a retro-authorization is requested an explanation must be included with the request as to why the authorization was not requested prior to the services being render . Past 7 days , the retro authorization request will need to be submitted as an appeal when the claim is completed , unless otherwise noted in the plan document .
When a prior authorization request results in a medical necessity denial , our physicians are available peer to peer conversation with the requesting provider within one business day of a request , if the request is received within 7 days of the denial . Another option is to submit additional clinical information within 7 calendar days of the denial for a reconsideration review by UM . If the denial is upheld , the provider must follow the appeal process per the member ’ s plan documents . If a prior authorization request is denied , it may not be resubmitted until after the appeal timeframe has expired .
The facility is responsible for providing timely admission notification and obtaining admission authorization even if a prior authorization had been obtained by the physician . This includes any add on services for observation stays or inpatient admissions when the member is kept overnight or longer after same day surgery or other scheduled and prior authorized services .
Admission notification and the request for authorization for admissions , observation stays , or an emergency outpatient procedure must be made within 24 hours of an emergent or urgent inpatient admission or observation stay for situations that occur on a weekday or by 5:00 p . m . Pacific time on the next business day for inpatient or outpatient stays that are initiated on a weekend or federal holiday , even if the patient was discharged over the weekend or the holiday . The facility and physician must be prepared to provide clinical documentation to support the medical necessity of the procedure or the facility stay .
Reimbursement Reductions for Lack of Timely Admission Notification
Notification Time Frame Admission notification received after it was due , but not more than 72 hours after admission .
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Reimbursement Reduction
100 % of the contracted rate for the days preceding notification
Admission notification received after it was |
due , and more than 72 hours after admission . |
100 % of the contracted rate ( entire stay ). |
No admission notification received . |
100 % of the contracted rate ( entire stay ). |
Appropriate clinical documentation that supports the medical necessity for hospital facility services must be supplied with the request for authorization . The Healthcare Utilization Management staff will review this documentation against nationally available criteria to determine whether medical necessity has been met for the facility stay . Hometown Health