Inpatient Hospital Notification and Authorization

An inpatient hospital notification is required for all members to ensure care coordination and that all inpatient hospital services paid under PrimeWest Health are medically necessary and consistent with the member’s diagnosis or condition and cannot be provided on an outpatient basis. Member eligibility is not determined through the notification process; eligibility should be verified on admission, and routinely thereafter. Authorization is required for inpatient stays if the provider is not located in Minnesota, North Dakota, South Dakota, Iowa, or Wisconsin.

All (contracted and non-contracted) hospitals shall comply with the following requirements:

  1. Notify PrimeWest Health of all emergency and non-emergency hospital inpatient admissions within 24 hours of the admission, or for admissions occurring during a weekend or holiday, by the end of the first working day thereafter.
    1. Failure to notify PrimeWest Health may result in denial or delay in payment of claims
  2. Make information related to the admission available to PrimeWest Health during the course of a member’s hospitalization. This information must be provided in the form of an update and will be requested by PrimeWest Health’s Utilization Management department in order to conduct concurrent and continued stay review. The medical records of the patient covered under PrimeWest Health are subject to retrospective review to determine the medical necessity of inpatient services. Inability to satisfy medical necessity will result in denial or delay in payment of claims.
  3. Make information regarding the time and date of discharge and information regarding the treatment provided to the member available to PrimeWest Health within the next working day following a member’s discharge

Submission of an explanation of benefits (EOB) from the primary insurance with the claim will help ensure accurate and timely reimbursement. In the event primary insurance denies the inpatient stay, PrimeWest Health would pay the entire claim if medical necessity is met using our criteria.

Providers may not seek payment from members for inpatient hospital services for which a Service Authorization is required but not issued.

Admissions Requiring Service Authorization

If Medicare denies or does not cover a service, all authorization rules apply. Reminder: All admissions require inpatient hospital admission notification within the first 24 hours regardless if a Service Authorization is required.

All inpatient stays requiring authorization will be subject to concurrent review and continued stay review.

The medical records of patients covered under PrimeWest Health are subject to retrospective review to determine the medical necessity of inpatient services.

OB Service Authorizations

Admissions for uncomplicated obstetric (OB) deliveries do not require an authorization; however, notification of the admission is required within one business day of the admission. If the newborn’s identifying information is not known at the time, send in notification of the mother’s admission and send in the newborn’s information as soon as possible afterwards.

The notification must include the following:

  1. The mother’s name, date of birth (DOB), and Person Master Index (PMI) number
  2. The newborn’s DOB, gender, weight, and name (if available)

Failure to notify PrimeWest Health with the above information following the OB delivery may result in denial or delay in payment on claims.

The newborn’s hospital stay has not, and will not, need a Service Authorization unless the newborn is inpatient longer than the mother and the hospital stay is at an out-of-state hospital that is also out of network.

Authorizations are only required by out-of-state providers if they are also out-of-network providers. Authorization is required for inpatient stays if the provider is not located in Minnesota, North Dakota, South Dakota, Iowa, or Wisconsin.

Concurrent, Continued Stay, and Retrospective Reviews

PrimeWest Health performs concurrent, continued stay for all members who require a Service Authorization at an out-of-state hospital that is not contracted with PrimeWest Health (i.e., out of network).

Retrospective reviews for all other members as indicated for all other admissions. All admissions of fewer than 48 hours will have a retrospective review done. A physician (secondary medical reviewer) is consulted if the medical record and other supporting information do not clearly demonstrate the medical necessity of the admission, continued stay, services provided, or the reasons for the member’s discharge and readmission.

PrimeWest Health reserves the right to review all inpatient admissions to determine medical necessity, even if an inpatient Service Authorization is not required or has already been granted. If this review (using InterQual® criteria) determines that the admission did not meet medical necessity criteria, the review will be forwarded for secondary medical review.

If the secondary medical reviewer (physician) determines medical necessity was not established, PrimeWest Health will withdraw the Service Authorization number (provided by PrimeWest Health to the hospital during initial review) and notify the admitting physician and the hospital of the withdrawal. A denial letter will also be provided along with Appeal rights.

If a Service Authorization number was not yet provided and the secondary medical reviewer (physician) determines that medical necessity was not established, PrimeWest Health will deny a Service Authorization number and notify the admitting physician and the hospital of the denial and Appeal rights.

Denial, Withdrawal, or Retrospective Denial of Coverage for Not Meeting Inpatient Criteria

If a Service Authorization number is withdrawn or it is determined that an admission that did not have a Service Authorization number is not medically necessary (did not meet inpatient hospital criteria) or the medical record does not adequately document that the admission was medically necessary, PrimeWest Health may deny or recover all or part of the PrimeWest Health payment made to the attending physician, hospital, and other providers of inpatient hospital services.

If the Service Authorization number is denied or withdrawn, the services may be billed as outpatient observation hospital services only if the following apply: an inpatient claim has been submitted and denied, inpatient charges have not been submitted, and the total time the member was in the hospital was less than 48 hours. For more information, review Outpatient Hospital Services.

Criteria to Determine Medical Necessity

PrimeWest Health’s nurse review staff uses InterQual® to determine medical necessity. InterQual® is a multi-specialty, clinically-based application that utilizes clinical literature, community standards of practice, and national practice guidelines to help determine medical need and intensity of services to manage certain conditions. The PrimeWest Health Utilization Management department uses the most current InterQual™ criteria, adopted clinical practice guidelines, Minnesota Department of Human Services (DHS) and State of Minnesota coverage policies, Centers for Medicare & Medicaid Services (CMS) national coverage determinations (dual eligible members only), local Medicare coverage determinations published by tNGS for Part B services and CGS for DEMPOS, and other PrimeWest Health-approved medical policies in its authorization decisions. Criteria are available upon request of the practitioner. The practitioner may request the criteria either by phone, fax, email, or by a written request sent via the United States Post Office. The criteria will be provided to the practitioner upon request through any of the distribution methods listed above or through either of the following methods:

  1. In person
  2. By telephone

Readmission

The medical records of inpatients readmitted to the hospital within 15 days will be reviewed retrospectively as indicated by PrimeWest Health. The initial admission, discharge, and the readmission are reviewed to monitor quality of care (e.g., underutilization of services, fragmented care, premature discharge) to determine if payment should be made for one or both hospitalizations, or if payment should be made according to transfer payment established by Minnesota Rules. If the decision is that the readmission is continuous with the previous admission, reconsideration may be requested through the provider Appeal process.

Medical records with clearly documented situations of patient preference, leaving the hospital against medical advice (AMA), patient noncompliance, physician/hospital convenience, or scheduling conflicts will not be sent through physician review. Situations of episodic illness (same or different episode) or prevailing medical standards, practice, and usage will be sent to physician review (secondary medical review) if the Utilization Management (UM) Care Coordinator cannot make a determination based on criteria and the information submitted for review. If the provider does not agree with it, reconsideration may be requested through the provider Appeal process.

Medical records of an admission must clearly state the following:

  1. The reason the member was discharged from the hospital
  2. The member’s status upon discharge

Medical records of a readmission must clearly state the following:

  1. The reason the member was readmitted
  2. The member’s medical status at readmission

Readmission Criteria

Criteria used to determine whether a readmission is considered a second admission, continuous with the first admission, or eligible for transfer payment are shown below.

Criteria: A second admission is a readmission that resulted from one of the following circumstances:

  1. During the first admission, the member left the hospital AMA once the member understood the hospital course (usually within the initial hours of hospitalization). This “admission” should be billed as outpatient services.
  2. During the first admission, the member was noncompliant with medical advice (i.e., the member was informed of his/her medical condition and fully understood the need for treatment and follow-up, yet refused to adhere to medical recommendations). The information provided to the member is documented in the medical record at the hospital of the first admission.
  3. A new episode of the same diagnosis of an episodic illness or condition
  4. The member was discharged and readmission was medically necessary according to prevailing medical standards, practice, and usage

Criteria: An admission continuous with the initial admission is a readmission that resulted from one of the following circumstances:

  1. The member was discharged from the admitting hospital without receiving the procedure or treatment for the condition diagnosed during the admission because of the physician’s or hospital’s preference or because of a scheduling conflict. If the admitting and readmitting hospitals are the same, the second admission is a continuation of the first, and only one Service Authorization number is to be provided to the provider. If the admitting and readmitting hospitals are not the same, the second hospital is given a new Service Authorization number. Both hospitals need to know that they are going to receive transfer payment (applies to DRG hospitals only).
  2. The member’s discharge was not appropriate according to prevailing medical standards, practice, and usage. InterQual® discharge criteria and, if necessary, secondary medical review, will be used to determine if discharge was appropriate. If the discharge was not appropriate and the admitting and readmitting hospitals are the same, PrimeWest Health will authorize only one admission (the readmission is a continuation of the admission). If the admitting and readmitting hospitals are different, PrimeWest Health may withdraw the Service Authorization number for the initial admission and a new Service Authorization number will be generated for the second hospital. If PrimeWest Health provides both hospitals with a Service Authorization number, both hospitals need to know that they are going to receive transfer payment (applies to DRG hospitals only).
  3. The preference of the member or his/her family that the treatment be delayed, the member be discharged without receiving the necessary procedure or treatment, and then the member be readmitted to the same hospital for the necessary procedure or treatment. In this situation, “preference” differs from AMA discharge because the choice is compatible with prevailing medical standards. If the admitting and readmitting hospitals are the same, the initial admission Service Authorization number will be given to the provider (the readmission becomes a continuation of the initial admission). If the admitting and readmitting hospitals are not the same, then a new Service Authorization number is entered for the second hospital, and both hospitals need to know that they are going to receive transfer payment. Transfer payment applies if the readmission to the new hospital is within hours of the discharge from the first hospital.
  4. The readmission results from the same episode of the same diagnosis/disease of an episodic illness or condition. For readmissions to physical rehabilitation after transfer to acute care, it is necessary to determine if the member’s treatment can resume at or near the pre-transfer stage. If so, combine the admission and readmission. If the patient physically regressed or the functional level deteriorated during the acute care hospitalization and the treatment program must be repeated, the readmission is considered a second admission. Although the decision is not based on the LOS in rehabilitation or an acute hospitalization, LOS must be considered.

Criteria: An admission eligible for transfer payment is an inpatient discharge followed by a readmission that resulted from the circumstances noted above (an admission continuous with the initial admission) and the following:

  1. The readmission results from a referral from one hospital to a different hospital because the member’s medically necessary treatment is outside the scope of the admitting hospital’s available services. In this case, both hospitals will have their own Service Authorization numbers if any of the following apply:
    1. The admitting hospital admitted the member as an emergency
    2. At the time of admission, the admitting hospital was unaware and had no reason to believe that the member’s treatment was outside the scope of the hospital’s available services
    3. There is a physician or hospital scheduling conflict at the admitting hospital and the readmission is at a different hospital

If the first admission did not meet any of the criteria listed above, the admission event for the first hospital is void and the hospital is asked to bill for outpatient services.

PrimeWest Health Contact Information

PrimeWest Health Utilization Management
3905 Dakota St
Alexandria, MN 56308

Fax: 1-866-431-0804 (toll free)
Phone: 1-866-431-0803 (toll free); Monday – Friday, 8 a.m. – 4:30 p.m.

PrimeWest Health Service Authorization forms can be found on the PrimeWest Health website.

Availability of Utilization Management Criteria

Utilization Management criteria are available upon request of the practitioner. The practitioner may request the criteria by telephone, fax, email, or by written request via the United States Post Office. The criteria will be provided to the practitioner upon request through any of the distribution methods listed above or through either of the following methods:

  1. In person
  2. By telephone

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Updated_10/08/2021