Inpatient Admissions Concurrent Review

Using recognized evidence-based criteria, QualChoice conducts concurrent review on all inpatient stays to ensure the medical appropriateness and necessity of continued hospitalization. Concurrent review also helps ensure effective discharge planning and care transitions. Pre-authorization and Concurrent Review Guidelines.

Inpatient Pre-admission Review

Pre-admission review is the process of confirming eligibility and collecting information prior to inpatient admissions and selected ambulatory procedures at in-network facilities.

Pre-admission review is required for:

  • All planned/elective admissions for acute care
  • All unplanned admissions for acute care
  • All institutional care not in an acute hospital, such as in a rehabilitation or skilled nursing facility
  • All admissions following outpatient surgery
  • All admissions following observation
  • All newborns admitted to Neonatal Intensive Care Unit (NICU)
  • All newborns who remain hospitalized after the mother is discharged (within 24 hours of the mother’s discharge)

Submit a Pre-authorization Request Form, found at QualChoice.com, or sign in to My Account and use the AutoAuth online pre-authorization system.

Inpatient Pre-certification Requirements

  • Pre-certification is the process of reviewing inpatient admissions to determine if hospitalization is medically necessary, or if needed services could be provided in an outpatient or alternative setting.
  • The provider/treating physician bears the primary responsibility for obtaining pre-certification. Calls are also accepted from the admitting facility or member.
  • Pre-certification does not guarantee payment. Granting pre-certification only means that, based on the information provided to QualChoice, the admission is considered to meet medical necessity guidelines for the days authorized.
  • Coverage and payment to all providers is subject to member eligibility, payment of premiums and all other terms and conditions of the member’s health plan.

 

Pre-certification
Elective Admissions Non-Elective Admissions Emergency Admissions
Within 5 business days prior to admission Weekday admissions: within 24 hours

Weekend/federal holiday admissions: by 5:00 p.m. local time on the next business day
Within 48 hours of admission or 2 business days after performed. If patient is unable to provide coverage information, the facility should notify QualChoice as soon as the information is known.


Submit a Pre-authorization Request Form, found at QualChoice.com, or sign in to My Account and use the AutoAuth online pre-authorization system.

Note: Notification by the facility is required even if it was supplied by the physician and a pre-authorization approval is on file.

Observation Services

Observation services are reimbursed according to the provider agreement for stays up to 24 hours. Hospital stays over 24 hours will not be reimbursed as observation. Observation services delivered in conjunction with outpatient surgery will only be reimbursed for a stay that extends more than 6 hours after completion of the surgery, and only if such stay is medically necessary. Facility charges are to be billed under revenue code 762.

Coverage Guidelines

  • Charges are recognized from general acute care hospitals only.
  • Hospital outpatient surgery fee schedule amount (global allowance) encompasses observation bed charges and related services.
  • Services occurring within 24 hours of a hospital admission are considered part of the inpatient hospital billing. The admission date is the day that the patient is first considered an observation patient. For purposes of pre-authorization (if applicable), the admission is treated as an emergency, so the 48-hour prior notice requirement does not have to be met.

Hospital Inpatient Readmissions

Unless otherwise stated in the facility contract, our policy is to deny readmissions within 72 hours of discharge and consider it part of the original admission. The readmission, however, may be appealed by the facility based on readmission guidelines and/or contract.

  • The original hospital stay is often called the index admission and the subsequent hospital stay is called the readmission.
  • QualChoice defines a readmission as within 30 days of discharge.
  • Same-day readmissions are considered a continuation of care and one claim should be submitted.
  • All readmissions are reviewed against QualChoice readmission guidelines and medical necessity criteria.
  • Determinations for approval or denial are based on readmission guidelines, medical necessity and/or a Medical Director decision.