Interim Guidance | May 18, 2020

Acute Care Observations and Admissions: COVID-19 Response Interim Guidance

Interim Acute Care Facility UM Rules: Effective 3/16/2020* – Expires 6/30/2020 (subject to renewal based on continuous reassessment of the pandemic impact)

*The effective date of this guidance is contingent on Community Health Options receiving a daily Admission, Discharge, Transfer (ADT) report that meets the additional criteria listed below.

  • Waiving Concurrent Review: Health Options will waive concurrent medical necessity review for Observation (Obs) and Inpatient (Inpt) stays at acute care facilities (hospitals) IF we receive a daily Admission, Discharge, Transfer (ADT) report sent via fax or encrypted email that includes the minimum necessary information.
  • Observation time frame is limited to 48 hours. Please make the decision to admit or discharge to a lower level of care within 48 hours.
  • Minimum ADT information (required):
    • Member name
    • DOB
    • Diagnosis
    • Admission Date (with time if feasible)
    • Designation: Observation Stay or Inpatient Admission
    • Discharge date (we will consider the status discharged if not listed)
  • Supplemental ADT information (preferred)
    • Level of Care (e.g., ICU, NICU, MedSurg)
    • Date transferred to a different level of care (LOC), when applicable
      • Please note if patient is deceased
    • Discharge disposition – Home, SNF, Rehab, etc. (if known)

ADT Daily Notification Options:

  • Fax submission: fax to Health Options at 877-314-5693
  • Email submission: send via encrypted messaging to ADT@healthoptions.org

 

Outpatient/Ambulatory Services UM requests:  COVID-19 Response Interim Guidance

Outpatient/Ambulatory Services Interim UM Rules: Effective: 3/16/2020– Expires: 6/30/2020 (subject to renewal based on continuous reassessment of the pandemic impact)

  • Extended Medical Authorization Date Range: Effective 3/16/2020, authorizations for Outpatient procedures and Ambulatory services that generally have a 90-day authorization date range will be issued for 180 calendar days through June 30, 2020.
  • Extended Behavioral Health Authorization Date Range: Effective 3/16/2020, authorizations for Outpatient Behavioral Health procedures and services that generally have a 90-day authorization date range will be issued for 180 calendar days through June 30, 2020. Impacted Behavioral Health services are:
    • Applied Behavioral Analysis
    • Assertive Community Treatment
    • Electroconvulsive Therapy
    • Neuropsychotherapy
    • Psychotherapy
    • Transcranial Magnetic Stimulation

Please note that Intensive Outpatient Program (IOP) and Partial Hospital Program (PHP) authorization review dates will not change.

  • eviCore: Effective 3/17/2020, authorizations submitted to eviCore that generally have a 60-day authorization date range will be issued for 180 calendar days through June 30, 2020.

 

Current Authorizations:

Health Options is actively working behind the scenes to update existing authorizations.

Our UM team is reviewing authorizations that were submitted and approved in 2020 and we are cross referencing approved authorizations against submitted claims.

  • If we find a claim on file for the authorization request, no further action will be taken.
  • If we do not find a claim on file, we are updating the existing authorization for an additional 180 calendar days.
    • We are sending updated letters to Members and providers to reflect the extended authorization date range.

We anticipate this process will be completed within one to two weeks.

Providers who prefer to fax a request to update an authorization should use the following process for Heath Options requests submitted since 1/1/2020 with a 90-day authorization date range and eviCore requests submitted since 1/15/2020 with a 60-day authorization date range:

  • Include the current authorization number with the update request.
  • Fax all Health Options and eviCore authorization update requests to Health Options at: (877) 314-5693

Health Options’ UM team will work with eviCore to update eviCore authorizations. Once the authorization is updated, notification will be sent to the Member and Provider(s).

 

Interfacility transport:  COVID-19 Response Interim Guidance

Interfacility Transport Interim UM Rules: Effective: 3/16/2020– Expires: 6/30/2020

(subject to renewal based on continuous reassessment of the pandemic impact)

Interfacility ambulance ground transport (ambulance) does not require Prior Approval if the patient is transported 200 miles or fewer:

  • from an acute care facility (unable to provide necessary care) to the nearest available higher level of care, or
  • from an acute care facility to a facility providing a lower level of care.

 

Admission to targeted non-acute settings UM requests:  COVID-19 Response Interim Guidance

 Admission to targeted non-acute settings Interim UM Rules: Effective: 3/16/2020– Expires: 6/30/2020

(subject to renewal based on continuous reassessment of the pandemic impact)

For initial stay at (INN) participating facilities, only notification is required, as follows:

  • Skilled Nursing Facility – within 3 business days
  • Acute Rehabilitation – within 3 business days
  • Home Health: within 48 hours of 1st visit

Then Prior Approval is required for ongoing care.

 

Durable Medical Equipment (oxygen) UM requests:  COVID-19 Response Interim Guidance

Durable Medical Equipment (oxygen) Interim UM Rules: Effective: 3/16/2020– Expires: 6//30/2020

(subject to renewal based on continuous reassessment of the pandemic impact)

Prior Approval for home oxygen assessments, oxygen and oxygen supplies has been waived for Members with a COVID-19 diagnosis.

 

If you have questions, please contact Provider Relations at (207) 402-3347 or provider@healthoptions.org