This article is for all acute care and other hospitals and facilities providing inpatient levels of care to our members
Updated October 22, 2020 to add authorization requirements by service requested and product, including if notification or medical necessity review is required. See table at the end of the article for details.
In June, we announced that we would waive authorization requirements associated with certain inpatient levels of care.
Recognizing that some inpatient acute care hospitals continue to have administrative resource issues due to COVID-19, we will extend our waiving of authorization requirements at inpatient acute care and mental health hospitals for dates of service on or before December 31, 2020. This applies to:
Through dates of service up to and including December 31, 2020, inpatient acute care hospitals and mental health hospitals must notify us of inpatient admissions. Timely notification serves to facilitate care coordination, mobilize additional services to support transition-of-care, and facilitate discharge planning. While this notification-only requirement is in place, we will not perform medical necessity reviews.
Starting with dates of service on or after January 1, 2021, authorization requirements will be reinstated. You will need to submit requests and supporting documentation for prior authorization at that time.
Consistent with what we announced in June, starting on October 1, 2020 we are resuming referral and prior authorization requirements for all other inpatient levels of care for commercial products (all products except FEP and Medicare). This includes long-term acute care (LTAC) hospitals, acute and subacute rehabilitation (rehab) facilities, and skilled nursing facility (SNF) admissions.
Authorization requirements by service and product
Effective October 1, 2020 for dates of service through December 31, 2020
|Notification only required||Does not require submission of clinical documentation for initial admission or concurrent review|
|Medical necessity review required||Requires that the requesting provider submit clinical documentation in support of the request|
|Level of care or service||Commercial HMO, Indemnity and PPO||Medicare Advantage||FEP|
|Behavioral health – inpatient||Notification only required|
|Behavioral health – acute residential treatment (partial hospitalization & intensive outpatient program)||Medical necessity review required|
|Emergent inpatient||Notification only required|
|Preservice inpatient||Notification only required (for dates of service through December 31, 2020)|
|Skilled nursing facility, rehabilitation, and long-term acute care hospitals
Benefit limits still apply
|Medical necessity review required||Notification only required||Medical necessity review required|
|Home health care
Benefit limits still apply
|Medical necessity review required||HMO
Notification only required
|No notification required|
|Other previously approved elective surgeries||Extended authorizations to be valid through December 31, 2020|
behavioral health testing (example: neuropsychological testing)
|Extended authorizations to be valid through December 31, 2020|
For more information, please refer to our Authorization Quick Tip.
Thank you for the care you provide to your patients—our members.