Harvard Pilgrim Health Care Home
  HPHConnect
 
  Learn more.
  Sign up for HPHConnect.
Medical Management
E-Transactions
HPHConnect
Pharmacy
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Newsroom
Office Support
Products
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
 
Print    Text Size

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

June 2019

Reminder: Notification and Concurrent Review for Inpatient Stays


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.

Notification requirements

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.

Additional information

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.

Email this article to a colleague   


Network Matters Archives

Download printer-friendly version

HPHCURRENT EVENTS

Harvard Pilgrim Network Meeting: Sign Up for our Andover Event

Reminder: Sign Up for a Webinar on Cardiac Diagnostic Imaging Authorization Program

GIC Product Updates Effective July 1

New Complex Care Program for Medicare Advantage Members

Child-Adolescent Mental Health Coverage for July 1, 2019

CLINICIAN CORNER

Update: Electronic Authorization & Use of InterQual®

Update: Maximum Dosages for Medical Drugs

Reminder: Notification and Concurrent Review for Inpatient Stays

Vonvendi to be Covered With Prior Authorization

Parsabiv to be Covered With Prior Authorization

Updates to Esophagogastroduodenoscopy Medical Policy

Argus II, CardioMems, and Coflex Not Covered as of Aug. 1

FreeStyle Libre System: Pharmacy Benefit for Commercial Members

OFFICE ASSISTANT

Keep Panel Status and Demographic Information Up to Date

2019 Home Care Seasonal Flu Vaccine Fee Schedule

Clarification: Appropriate Use of Modifier 91

PUBLICATION INFORMATION

Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator