As a reminder, Harvard Pilgrim applies a concurrent review program for inpatient admissions to acute care hospitals, acute rehabilitation and long-term acute care hospitals, and skilled nursing facilities to ensure that our members receive evidence-based, well-coordinated, and cost effective health care.
The concurrent review process includes obtaining and utilizing clinical information provided by facility staff to determine the appropriateness of the level of care and to assist in the discharge planning process. Harvard Pilgrim’s nurse care managers conduct outreach to the appropriate staff from the facility’s case management, care coordination, or discharge planning departments by telephone beginning as early as the third day of the member’s stay.
For this review, the nurse care managers will apply InterQual Criteria, a nationally accepted standard medical necessity criteria set from McKesson/ChangeHealthcare. The nurse care managers continue the review throughout the Harvard Pilgrim member’s stay, depending on the member’s clinical status and the standards outlined in the InterQual criteria. For most members, reviews continue to occur every two days.
Harvard Pilgrim will notify facility staff of coverage determinations in a timely manner and, in certain circumstances, may refer the case for physician review. For more information on our concurrent review program, please refer to the Clinical Decisions policy in Harvard Pilgrim’s online Provider Manual.