Pre-Authorization is required for all inpatient, partial hospitalization and intensive outpatient services
Emergency Inpatient Admissions: The only exception to this rule is for emergency cases where it is not possible to obtain pre-authorization due to critical or possible life-threatening circumstances Emergency circumstances are situations that would lead a prudent layperson, possessing an average knowledge of health and medicine, to reasonably expect the absence of immediate medical attention to result in any of the following: 1) placing the health of an individual in serious jeopardy; 2) serious impairments to bodily functions; 3) serious dysfunction of any bodily organ or part, or; 4) death. In those instances, the provider must notify CBHA as soon as possible, but in all cases within 48 hours of the provision of emergency services or by the end of the first business day following the rendering of such services, whichever is later. Retroactive authorization may be granted if the situation meets the criteria for emergency admission. In instances where the facility does not obtain pre-certification and there is no emergency justification, the facility will be administratively sanctioned for the period prior to the initial request for certification.
Facilities are to call 1-800-475-7900 to pre-authorize all admissions 24 hours a day, 7 days a week. A CBHA clinician will gather and document information necessary to determine the appropriate level of care based upon medical necessity criteria and to verify the enrollee's eligibility and benefit structure as provided by the affiliated health plan. Required information includes, but is not limited to the following:
Note: Initial reviews after hours or on weekends or holidays will require a follow-up review for the next business day to verify eligibility. If the enrollee is not covered, CBHA staff will notify the facility of the lack of benefit within 24-hours or the next business day.
CBHA Clinical Care Managers may authorize a 23-hour observation bed to provide an opportunity for a more extensive evaluation and formulation of a treatment plan for an inpatient request.
In cases where the Clinical Care Manager is unable to determine whether medical necessity criteria are met, the facility will be notified and a peer to peer review will be conducted by the CBHA Medical Director or Assistant Medical Director. This review will be conducted within 24 hours of the request or by the next business day. If the review determines the presence of medical necessity criteria, an authorization will be issued. If the review indicates no medical necessity, the clinical care manager will immediately notify the facility via telephone, informing the facility of the right to file an appeal, and will issue a Notice of Services Not Certified to the provider and the enrollee. Facility-Based Authorizations - Concurrent Reviews
When an initial/previous request has been authorized and a concurrent review is due, it is the facility's responsibility to contact CBHA to obtain additional authorization. The following information is required from the facility:
Once information is provided that justifies medical necessity for the level of care, the Clinical Care Manager will authorize additional days as indicated.
In cases where the Clinical Care Manager is unable to determine whether medical necessity criteria are met, the facility will be notified and a peer to peer review will be conducted by the CBHA Medical Director or Assistant Medical Director. This review will be conducted within 24 hours of the request or by the next business day. If the review determines the presence of medical necessity criteria, an authorization will be issued. If the review indicates no medical necessity, the clinical care manager will immediately notify the facility via telephone, informing the facility of the right to file an appeal, and will issue a Notice of Services Not Certified to the provider and the enrollee.
Non-Authorizations for Concurrent Inpatient Reviews: In instances where a non-authorization determination is made, CBHA remains responsible for covered behavioral health services until the network provider and/or the enrollee has been notified of the non-authorization. Notification to the enrollee may be through hospital staff, physician or CBHA's clinical care management staff
Facilities are responsible to contact CBHA to report a discharge on the date it occurs and to supply the following information:
An Authorization for Services letter will be sent within 72 hours of the notification of discharge.
HEDIS Standards and Inpatient Discharge
CBHA strives to meet or exceed HEDIS standards for 7-day and 30-day follow up after an inpatient stay for all members who have been hospitalized. CBHA expects that all network hospitals will work to have a member an appointment within 7 days of discharge and that the hospital will send an expedited discharge summary to the outpatient treatment providers. CBHA tracks all network facilities' compliance to HEDIS standards for discharge follow-up after hospitalization. If a hospital is having difficulty obtaining an outpatient appointment within 7 days of discharge, the facility may call a CBHA Clinical Care Manager at (800) 475-7900 to request assistance.
In instances where an individual is being discharged from an inpatient setting to a partial hospitalization or intensive outpatient program, the clinical care manager documents the above discharge information, along with information documenting medical necessity for the partial hospital or intensive outpatient program. The authorization for the new level of care may not begin until the next working day after discharge.