Licensed vocational nurses LVNs, also called licensed practical nurses or LPNs in some states provide compassionate, hands-on care to people of all ages, from newborns to senior citizens.
Must give no less than 48 hours to provide. Decision is due within 48 hours of receipt of the additional information Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.
Payment implications for failure to pre-authorize services Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off.
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Our members must be held harmless and cannot be balance billed. Please note the following: Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services.
We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient.
If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any pre-authorization penalties for failure of the facility to provide the required inpatient admission and discharge notification.
A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits.
Services must always be medically necessary. If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity. Pre-authorization exception There may be exceptions to obtaining pre-authorization.
Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification. Member is unable to communicate e.
Neither family nor collateral support present can provide coverage information. Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
Services are subject to review post-service for medical necessity A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.
Inpatient admissions See below for chemical dependency and mental health admissions Hospital admissions, including inpatient hospice Notification for a hospital admission or discharge is necessary within 24 hours of admission or discharge or one business day, if the admission or discharge occurs on a weekend or a federal holiday.
Notification is required via electronic medical record, when available. If electronic medical records are not available, notifications are required via fax.
Learn more about this requirement. Rehabilitation Pre-authorization is required prior to patient admission.The staffing trend values will differ from prior year budget books in order to show amounts without the impact of any vacancy factors.
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