Section 20: Review Types Time Frame to Review Type Submission Method/ Description Completion & Review Components Notification Pre-Service Review Web portal conduct pre-service reviews Non-urgent; Fifteen Secure fax for selected diagnosis and calendar days Telephone procedures that require prior authorization Urgent; Three business days Psychiatric Hospital Web portal Conduct pre-service reviews Pre-Admission Non-urgent; and Continued Secure fax of all admissions of Fifteen calendar days Stay Review under 21 Telephone Participants under the age of 21 with primary psychiatric Pre-Admission Urgent; diagnoses according to Three business days IDAPA 16.03.09 Sections 700-719 Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Web portal Conduct medical necessity Concurrent Non-Urgent: Continued Stay Review for Secure fax review of services that Three business days stays exceeding previously Telephone received pre-service authorized hospital stays authorization when the stay Concurrent Urgent: Three reaches the scheduled business days discharge date and discharge is not anticipated Web portal Conduct review of medical Concurrent Non-Urgent: Continued Stay Reviews for Secure fax necessity for Three business days all hospital admissions Telephone diagnosis/procedures that exceeding 3 days length of do not require pre-service Concurrent Urgent: Three stay review when the length of business days stay exceeds three days Web portal Conduct review for medical Concurrent Non-Urgent: Continued Stay Review for Secure fax necessity when the length of Three business days Cesarean Section hospital Telephone stay exceeds four days (only stays if the primary diagnosis code Concurrent Urgent: Three is identified as needing this business days review by the Department) Retrospective Pre-Payment Web portal Conduct review for Within thirty calendar days Reviews Secure fax outpatient or inpatient from receipt of all necessary Telephone hospitalizations where the documentation primary diagnosis or procedure would have required pre-service review or when the hospitalization exceeded three days Focused Case Reviews Web portal Conduct review of complex Within fourteen calendar Secure fax cases, high cost procedures days of receipt of all Telephone and other cases as requested necessary information by the Department
Section 20: Review Types Review Type Submission Method/ Review Components Description Time Frame to Completion & Notification Pre-Service Review Web portal Secure fax Telephone conduct pre-service reviews for selected diagnosis and procedures that require prior authorization Non-urgent; Fifteen calendar days Urgent; Three business days Psychiatric Hospital and Continued Stay Review under 21 Web portal Secure fax Telephone Conduct pre-service reviews of all admissions of Participants under the age of 21 with primary psychiatric diagnoses according to IDAPA 16.03.09 Sections 700-719 Pre-Admission Non-urgent; Fifteen calendar days Pre-Admission Urgent; Three business days Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Continued Stay Review for stays exceeding previously authorized hospital stays Web portal Secure fax Telephone Conduct medical necessity review of services that received pre-service authorization when the stay reaches the scheduled discharge date and discharge is not anticipated Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Continued Stay Reviews for all hospital admissions exceeding 3 days length of stay Web portal Secure fax Telephone Conduct review of medical necessity for diagnosis/procedures that do not require pre-service review when the length of stay exceeds three days Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Continued Stay Review for Cesarean Section hospital stays Web portal Secure fax Telephone Conduct review for medical necessity when the length of stay exceeds four days (only if the primary diagnosis code is identified as needing this review by the Department) Concurrent Non-Urgent: Three business days Concurrent Urgent: Three business days Retrospective Pre-Payment Reviews Web portal Secure fax Telephone Conduct review for outpatient or inpatient hospitalizations where the primary diagnosis or procedure would have required pre-service review or when the hospitalization exceeded three days Within thirty calendar days from receipt of all necessary documentation Focused Case Reviews Web portal Secure fax Telephone Conduct review of complex cases, high cost procedures and other cases as requested by the Department Within fourteen calendar days of receipt of all necessary information
ProviderManual.docx