1. In-network Observation stays do not require prior-authorization.
2. Hospital stays that include less than two bed days (less than “two midnights”) at the time of submission will be categorized as Observation Level of Care with some exceptions:
a. Obstetrical deliveries
b. Patient deaths
c. Against Medical Advice (AMA) discharges
d. Intensive Care Unit (ICU) admissions
e. Pediatric Intensive Care Unit (PICU) admissions
f. Pediatric Progressive Care Unit (PCU)
g. Initial Neonatal Intensive Care Unit (NICU) admissions
h. Neonatal Intensive Care Unit (NICU) readmissions within 28 days
i. Behavioral Health admissions
j. On a case by case basis following a peer to peer discussion between the Medical Director/Physician Reviewer and the attending physician or physician of record. The decision to admit a patient to inpatient status requires complex medical judgement including consideration of the patient’s medical history and current medical needs, the certainty of a hospitalization lasting greater than 48 hours, and high patient acuity and intensity of services.
3. All requests for prior authorization for inpatient admissions are received via fax, phone or mail by the Utilization Management Department and processed during normal business hours.
4. Texas Children’s Health Plan requires clinical documentation to be provided to support the medical necessity of the inpatient care, including but not limited to: emergency room note, admission and clinical notes, pertinent labs, consults, and treatment plans.
5. Texas Children’s Health Plan covers medically-necessary acute inpatient level of care when the services meet accepted standards of InterQual® Acute Level of Care Criteria. Acute criteria address the observation, acute, intermediate, critical, and extended stay levels of care for specific and general, medical, and surgical conditions. Pediatric criteria also include levels of nursery care: neonatal intensive care, special care, and newborn nursery. .
6. An outpatient observation patient may be advanced to inpatient status after 48 hours when it is determined the patient’s condition and intensity of service meet inpatient criteria as defined by InterQual® Day 1 criteria.
7. All requests for Inpatient admissions that do not meet the guidelines referenced here will be referred to a Texas Children’s Health Plan Medical Director/Physician Reviewer for review and the Denial Policy will be followed.
8. Preauthorization is based on medical necessity and not a guarantee of benefits or eligibility. Even if preauthorization is approved for treatment or a particular service, that authorization applies only to the medical necessity of treatment or service. All services are subject to benefit limitations and exclusions. Providers are subject to State and Federal Regulatory compliance and failure to comply may result in retrospective audit and potential financial recoupment.
References:
Government Agency, Medical Society, and Other Authoritative Publications:
Texas Medicaid Provider Procedures Manual April 2017 -
http://www.tmhp.com/TMHP_File_Library/Provider_Manuals/TMPPM/2015/Apr_2017%20TMPPM.pdf