22-595 Prepare for Utilization Management Changes

Date: 07/29/22

This information applies to Hospitals.

To reduce administrative burden, we are making changes to peer-to-peer review and elective medical inpatient authorization process timelines

Wellcare By Health Net (Health Net*) is making changes to:

• Peer-to-peer review request requirements.
• Elective medical inpatient authorization process.

See below for applicable effective dates.

Peer-to-peer review requests change effective October 1, 2022

Effective October 1, 2022, to ensure accurate delivery and reimbursement for medically necessary services, the Plan is updating the requirements for peer-to-peer review to the following:

• Peer-to-peer review requests will be allowed up to two business days after an Integrated Denial Notice or day of discharge, whichever is later.
• Peer-to-peer outreach will be completed within two business days of peer-to-peer review request.
• If provider is not reached, a voice mail will be left (if possible) giving the provider one business day to respond.
• If the provider does not respond within the timeframe, the Plan will be unable to proceed with peer-to-peer request.

There are no changes to existing peer-to-peer timeframes or processes for pre-service requests.

Elective medical inpatient authorization process change effective November 1, 2022

Effective November 1, 2022, to provide increased flexibility and to better align with industry best practices, the following changes apply to elective medical inpatient authorization process:

• The prior authorization span for elective inpatient admissions will be increased to 60 days for dates-of-service on or after November 1, 2022.
• If the planned admission date exceeds the authorized date span of 60 days, a new authorization span is required.
• Elective inpatient prior authorization numbers will now start with the prefix of OP instead of IP.
• Notification of admission is required within one business day of admission. At the time of admission notification, a new authorization number for the admission will be provided with the IP prefix. Failure to provide timely notification may result in a denial of payment.

Reminder

All planned/elective admissions to the inpatient setting require prior authorization. Request prior authorizations at least five days prior to the scheduled service delivery date or as soon as the need for service is identified.

If prior authorization is not on file at the time of elective admission, the service is considered retrospective. Follow the appropriate retrospective request process.

Emergency admissions do not require prior authorization.

Additional information

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the Provider Services Center within 60 days at 800-929-9224.