We want to share a few reminders on policies that Harvard Pilgrim has in place to ensure our members receive evidence-based, well-coordinated, and cost-effective care during inpatient stays.
Harvard Pilgrim requires notification for all emergent and non-emergent inpatient admissions. Admitting hospitals must 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.
The preferred method of notification is electronic through HPHConnect or NEHEN; however, we also accept notification by fax (800-232-0816) or by phone (800-708-4414).
If the admitting facility does not submit 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
Harvard Pilgrim’s nurse care managers conduct concurrent review of all inpatient admissions using InterQual criteria to ensure that the appropriate level of care is being applied and assist in discharge planning. In some cases, the nurse care manager may contact the case management staff at the facility to request additional information and discuss the appropriate level of care.
Review continues throughout the Harvard Pilgrim member’s stay (typically occurring every two days), depending on the member’s clinical status and the standards outlined in the InterQual criteria.
If a member does not meet criteria for an inpatient stay, Harvard Pilgrim may contact the facility to discuss the case 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, as Harvard Pilgrim does not provide reimbursement for observational services that exceed 48 hours.
If a facility does not agree with a recommendation of observation, the case will be reviewed by a Harvard Pilgrim physician to determine if inpatient criteria is met. If the Harvard Pilgrim physician reviewer determines that the member could have been safely treated at a lower level of care, the inpatient admission claim will be denied.
For more information, please refer to the Clinical Decisions, Emergent Department/Urgent Admissions Notification, Elective Admission Notification, and Denials and Adverse Determination policies in our online Provider Manual. If you would like to discuss the appropriate level of care, Harvard Pilgrim’s Utilization Management department may be reached at 888-888-4742.