Inpatient Admissions. The Member’s provider will need to obtain Prior Authorization from The Plan for an inpatient admission, if inpatient admissions are identified as needing a Prior Authorization. In the case of an elective inpatient admission, if services require an authorization it is recommended that the call for Prior Authorization should be made at least two working days before the Member is admitted. If the admission is due to an Emergency Medical Condition and obtaining Prior Authorization would delay Emergency Services, it is recommended that Prior Authorization should take place within two working days after admission, or as soon thereafter as reasonably possible. If Prior Authorization is not obtained for inpatient services and the services are denied as not Medically Necessary, the Participating Provider will be held financially responsible and will not be able to bill the Member for the services. If the provider is not a network provider then the Member, the Member’s provider, or the Member’s authorized representative should obtain Prior Authorization by The Plan by calling the toll-free number shown on the back of the Member’s identification card. The call should be made between 8:00 a.m. and 5:00 p.m., Mountain Time, on business days. After business hours or on weekends, please call the toll-free number listed on the back of the Member’s identification card. The Member’s call will be recorded and returned the next business day. A benefits management nurse will follow up with the Provider’s office. All timelines for Prior Authorization requirements are provided in keeping with applicable state and federal regulations. In-Network Benefits will be available if the Member uses an In-Network provider or In-Network specialty care provider. If the Member elects to use Out-of-Network providers for services and supplies available In-Network, Out-of-Network Benefits will be paid. However, if care is not reasonably available from In-Network providers as defined by applicable law, and The Plan authorizes the Member’s visit to an Out-of-Network provider to be covered at the In-Network Benefit level prior to the visit, In-Network Benefits will be paid; otherwise, Out-of-Network Benefits will be paid. When Prior Authorization of an inpatient admission is obtained, a length of stay is assigned. The Member’s provider may seek an extension for the additional days if the Member requires a longer stay. Benefits will not be available for room and board charges for medically unnecess...
Inpatient Admissions. The CONTRACTOR shall maintain a procedure to identify and evaluate member utilization of inpatient services by PCP panel.
