the requirements of this section [Carrier] reduces what it pays for covered Hospital charges as a penalty. Pre-Hospital Review All non-Emergency Hospital admissions must be reviewed by [ABC] before they occur. The Covered Person or the Covered Person's Practitioner must notify [ABC] and request a pre-hospital review. [ABC] must receive the notice and request as soon as possible before the admission is scheduled to occur. [For a maternity admission, a Covered Person or his or her Practitioner must notify [ABC] and request a pre-hospital review at least [60 days] before the expected date of delivery, or as soon as reasonably possible.] When [ABC] receives the notice and request, [they] evaluate: the Medical Necessity and Appropriateness of the Hospital admission the anticipated length of stay and the appropriateness of health care alternatives, like home health care or other care. [ABC] notifies the Covered Person's Practitioner [by phone, of the outcome of their review. And [they] confirm the outcome of [their] review in writing.] If [ABC] authorizes a Hospital admission, the authorization is valid for: the specified Hospital; the named attending Practitioner; and the authorized length of stay. The authorization becomes invalid and the Covered Person's admission must be reviewed by [ABC] again if: he or she enters a Facility other than the specified Facility he or she changes attending Practitioners; or more than [60 days] elapse between the time he or she obtains authorization and the time he or she enters the Hospital, except in the case of a maternity admission. Emergency Admission [ABC] must be notified of all Emergency admissions by phone. This must be done by the Covered Person or the Covered Person's Practitioner no later than the end of the next regular working day or as soon as possible after the admission occurs. When [ABC] is notified [by phone,] they require the following information: the Covered Person's name, social security number and date of birth; the Covered Person group plan number; the reason for the admission the name and location of the Hospital when the admission occurred; and the name of the Covered Person's Practitioner. Continued Stay Review
the requirements of this section [Carrier] reduces what it pays for covered Hospital charges as a penalty. Pre-Hospital Review All non-Emergency Hospital admissions must be reviewed by [ABC] before they occur. The Covered Person or the Covered Person's Practitioner must notify [ABC] and request a pre-hospital review. [ABC] must receive the notice and request as soon as possible before the admission is scheduled to occur. [For a maternity admission, a Covered Person or his or her Practitioner must notify [ABC] and request a pre-hospital review at least [60 days] before the expected date of delivery, or as soon as reasonably possible.] When [ABC] receives the notice and request, [they] evaluate: the Medical Necessity and Appropriateness of the Hospital admission the anticipated length of stay and the appropriateness of health care alternatives, like home health care or other care. [ABC] notifies the Covered Person's Practitioner [by phone, of the outcome of their review. And [they] confirm the outcome of [their] review in writing.] If [ABC] authorizes a Hospital admission, the authorization is valid for: the specified Hospital; the named attending Practitioner; and the authorized length of stay. The authorization becomes invalid and the Covered Person's admission must be reviewed by [ABC] again if: he or she enters a Facility other than the specified Facility he or she changes attending Practitioners; or more than [60 days] elapse between the time he or she obtains authorization and the time he or she enters the Hospital, except in the case of a maternity admission. Emergency Admission [ABC] must be notified of all Emergency admissions by phone. This must be done by the Covered Person or the Covered Person's Practitioner no later than the end of the next regular working day or as soon as possible after the admission occurs. When [ABC] is notified [by phone,] they require the following information: the Covered Person's name, social security number and date of birth; the Covered Person group plan number; the reason for the admission the name and location of the Hospital when the admission occurred; and the name of the Covered Person's Practitioner. Continued Stay Review
policyb_e.docx