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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

June 2017

Review of Inpatient Admissions for Appropriate Level of Care

As you know, Harvard Pilgrim requires notification for all emergent and non-emergent inpatient admissions. For dates of service beginning September 5, 2017, Harvard Pilgrim will be reviewing inpatient admissions against InterQual criteria — a nationally accepted standard medical necessity criteria set from McKesson/ChangeHealthcare — to ensure that the appropriate level of care (inpatient vs. observational admission) is being applied. In addition, Harvard Pilgrim will not provide reimbursement for observational services that exceed 48 hours.

Notification requirements

Harvard Pilgrim’s notification requirements for inpatient admissions continue to apply. Admitting hospitals are required to notify Harvard Pilgrim within two business days following a member’s emergent/urgent admission and at least one week before the admission or date of service for elective inpatient admissions.

Notification may be provided in one of the following ways: electronically through HPHConnect or NEHEN; by fax (800-232-0816); or by phone (800-708-4414).

If the admitting facility does not provide the proper notification, Harvard Pilgrim will not provide reimbursement and the facility will be liable. Members cannot be held liable for claims denied for failure to notify.

Review by care management staff

Inpatient admissions will be subject to review by one of Harvard Pilgrim’s nurse care managers to determine whether the patient meets InterQual Criteria for an inpatient stay. In these cases, one of Harvard Pilgrim’s nurse care managers may contact the case management staff at the acute care hospital to request additional information and discuss the appropriate level of care.

If a member does not meet criteria for an inpatient stay, Harvard Pilgrim will notify the facility and recommend observation level of care. If there is agreement, the facility may submit the claim as an observational stay for up to 48 hours. However, if the facility disagrees with the recommendation of observation status, the case will be reviewed by a Harvard Pilgrim physician reviewer and a denial of the inpatient stay may result.

Additional information

For more information, please refer to the updated Clinical Decisions, Emergent Department/Urgent Admissions Notification, Elective Admission Notification, Denials and Adverse Determination policies in the online Provider Manual. If you would like to discuss the appropriate level of care (inpatient vs. observational), Harvard Pilgrim’s Care and Utilization Management department may be reached at 888-888-4742.

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Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator