Concurrent and Retrospective Review
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Concurrent Review
Concurrent review is the process of monitoring delivery of medical services at the time the care is being rendered (inpatient admissions). Concurrent review consists of pre-admission review, continued-stay review and discharge planning.
Concurrent review is initiated at the time prior authorization is requested for an inpatient admission or on notification to the Health Net Medical Management Department that a member has been admitted (in the case of an urgent or emergency admission). Concurrent review includes an evaluation of:
- Quality of care
- Plan of treatment
- Severity of illness
- Intensity of treatment
- Length of stay
- Level of care
- Discharge plan
Based on the concurrent review process, the hospital stay is approved or denied. If the stay is approved, the hospital receives a prior authorization number. The authorization number must be indicated on the hospital claim to Health Net.
All potentially non-approved services identified by the Health Net care manager (registered nurse (RN) reviewer) are reviewed with a Health Net medical director or a specialty advisor. Physicians and members have the right of appeal all un-approved services. Care cannot be discontinued until the treating provider has been notified and agreed to an appropriate discharge or transition of care plan.
Behavioral Health Concurrent Review
- The attending physician or facility utilization review staff calls the Health Net Utilization Review Clinician on the agreed-upon review date and provides and verifies the concurrent review information.
- The Utilization Review Clinician obtains all of the following information required for concurrent review via phone with the utilization review staff or attending psychiatrist at the facility:
Diagnosis
- Symptom progress/change in severity
- Risk areas
- Treatment goals/interventions
- Medications
- Indicators for continued treatment
- Discharge planning (to begin at the time of admission)
- Target discharge date
- Other clinical information, as needed
Providers must notify the Health Net Utilization Review Clinician via phone on the same day that the member is discharged and provide a detailed discharge summary within 24 hours. The discharge summary must include information about the member’s status at discharge, such as current symptoms and medications, details about post-discharge appointment(s) scheduled for step-down care, and the member’s updated contact information (i.e., address, phone number).
- The Utilization Review Clinician reviews clinical data and authorizes additional days if medical necessity criteria for a continued stay are met.
- If the medical director denies authorization, refer to the non-certification procedure.
- If medical necessity criteria for a continued stay are not met for the level of care requested, the Utilization Review Clinician will review the request with a Health Net medical director.
- If the medical director denies authorization, refer to the non-certification procedure.
- The Utilization Review Clinician documents clinical appropriateness.
- The Utilization Review Clinician consults with a clinical manager and/or a medical director when any aspect of the treatment plan is unclear or in question.
Behavioral Health Noncertification
For most health plans, requesting facilities are notified by phone immediately of the review decision.
- The Health Net Utilization Review Clinician receives requests for initial authorization from the clinical contact at the facility or program by online submission, via the Availity Essentials secure provider portal, fax or phone. The Health Net Utilization Review Clinician receives any subsequent requests for continued stay from the clinical contact by phone.
- Administrative denials (based on exhaustion of benefits, lack of pre-authorization, etc.) do not require Health Net medical director review.
- When medical necessity criteria do not appear to be met, the Utilization Review Clinician presents the case to the medical director for review. In some clinical denials, the facility is notified by the Utilization Review Clinician that they can request a peer-to-peer discussion with the peer reviewer who originally denied the authorization. If the denial decision is not changed following peer-to-peer review discussion and the patient or facility still disagrees with the determination, the patient or patient’s representative (often the facility) can request an appeal by a different peer reviewer if the patient is still in treatment.
- Notification of denial of authorization is typically made by phone immediately, but not longer than permitted based on the type of account. For urgent concurrent requests, written confirmation is sent within 24 hours of receipt of request.
- The original denial letter is sent to the patient and copies are sent to the facility, parent and/or guardian (if applicable) and attending physician. The denial letter will always include the rationale for the denial decision and a full description of the appeals procedure.
In case of inpatient treatment services where the member is still hospitalized, a practitioner who wishes to appeal a denial immediately on behalf of the member is verbally notified of the urgent/expedited appeals process, in which the facility representative (e.g., attending physician) can speak with another peer reviewer to present the case.
All service requests that do not meet medical necessity approval criteria as described herein, or where medical necessity is questionable or unclear, must be reviewed by a Health Net medical director.
Retrospective Review
Retrospective review is review of the quality and necessity of medical services after care has been rendered. Retrospective professional review involves an evaluation of services that fall outside Health Net's established guidelines for coverage. These claims are reviewed by Health Net's professional review specialists (RN reviewers) and a Health Net medical director or a specialty advisor where the initial reviewer recommends that a claim be denied for lack of medical necessity.