uses MCG , Hayes Technology Assessments , CMS , or other peer reviewed guidelines to make these determinations for admissions and concurrent reviews . MCG guidelines are available for acute and sub-acute medical , rehabilitation , skilled nursing facilities , home health care , and ambulatory services . For an inpatient stay , an initial length of stay is assigned for each case . Both facilities and physicians must cooperate with Hometown Health ’ s requests for information , documents , or discussions for purposes of concurrent review and discharge planning including , but not limited to , clinical information , treatment plans , patient status , discharge planning needs , barriers to discharge , and discharge date . Facilities and physicians need to cooperate with Hometown Health ’ s requests for information from its Healthcare Utilization Management Department case managers or Medical Director for review to enable coverage to be extended for services .
When the member is ready for discharge , Healthcare Utilization Management staff will be available to work with the facility discharge planning staff as needed to obtain any services that the member may require from Hometown Health contracted network providers .
Retrospective Review
Retrospective review is an initial review of services after services have been provided to a member . This may occur when authorization or timely notification to Hometown was not obtained due to extenuating circumstances ( i . e . member was unconscious at presentation , member did not have their Hometown Health ID card or otherwise indicated other coverage , services authorized by another payer who subsequently determined member was not eligible at the time of service ). Requests for retrospective review must be submitted within 90 days from the date of explanation of payment unless otherwise outlined in the provider agreement . Provider ’ s failure to submit requests within such time period will result in the request being denied by Hometown Health . A request for retrospective review must also include any necessary supporting documentation including the reason / s as to why the authorization request was not submitted prior to services being rendered . If no reasoning is provided the request for retrospective review will be denied .
If Hometown Health is unable to authorize any portion of the stay or treatment , the attending physician , facility , or PCP will be contacted to provide additional information .
If a retro-authorization is granted , benefits will be paid only for those days or treatment approved by Hometown , under the Utilization Management Program , Scope of the Program , Prior-Authorization Process , or Concurrent Review / Case Management .
Providers should consult Link to check for services that require a prior authorization through the Eligibility section in Link . The Authorization Matrixes under the Forms tab will show the most current authorization requirements specific to the member ’ s plan .
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