Common use of After Hours Services Clause in Contracts

After Hours Services. Members who need medical services after normal hours should contact their PCP. The PCP’s answering service may take the Member’s call. If so, the answering service will contact the Member’s physician or the physician on call, who will contact the Member as soon as possible. After hours calls should be limited to medical problems requiring immediate attention. However, Members should not postpone calling their PCP’s office if they believe they need medical attention. • All continuing care as a result of Emergency Services must be provided or Referred by a Member’s Primary Care Physician or coordinated through Keystone’s Customer Service Department. • Some services must be Preauthorized by the HMO. Your Primary Care Physician or Participating Specialist works with the HMO's Care Management and Coordination team during the Preauthorization process. Services in this category include, but are not limited to: hospitalization; certain outpatient services; Skilled Nursing Facility services; and home health care. Services that require Preauthorization are noted in the attached Medical Care Preauthorization Schedule included with this Agreement. You have the right to appeal any decisions through the Member Complaint Appeal and Grievance Appeal Process. Instructions for the appeal will be described in the denial notifications. • All services must be received from Participating Providers within Keystone’s Limited Eligibility & Service Area unless Preauthorized by Keystone, or except in cases requiring (1) Emergency Services or Urgent Care while outside Keystone’s Limited Eligibility & Service Area but within Keystone’s Approved Service Area; (2) Emergency Service, Urgent Care and follow-up care under the BlueCard Program while outside Keystone’s Approved Service Area; or (3) Guest Membership Benefits under the Away From Home Care Program while outside Keystone’s Approved Service Area. See Sections ER – Emergency, Urgent, Follow-up Care and GM – Away From Home Care Program Guest Membership Benefits. See also Section ACC - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Provider. Keystone Members may submit a written request for a written list of Participating Providers affiliated with participating Hospitals. Use your Provider Directory to find out more about the individual Providers and their qualifications, including Hospitals and Primary Care Physicians and Participating Specialists and their affiliated Hospitals. The directory also lists whether the Provider is accepting new patients. • To change Primary Care Physician, call Keystone’s Customer Service Department at the telephone number shown on the ID Card or go to Keystone’s website at xxxxxxxxxxxx.xxx. • Services Coordinated By The Contracted Behavioral Health Management Company. Members seeking mental health care and substance abuse services may obtain preauthorization for such services from the contracted behavioral health management company. The contracted behavioral health management company may refer members to participating providers for mental health care and substance abuse services and may also coordinate emergency care for such services. Members may contact the contracted behavioral health management company by calling 1-800- 000-0000 (TTY number: 711). Any such services which are not coordinated, or which exceed the services authorized by the member’s PCP or the contracted behavioral health management company, are not covered. For outpatient non-emergency services to be covered, the services must be received from a Participating Provider and must have a prior notification by the contracted behavioral health management company. If a need for inpatient care or partial hospitalization is identified, the inpatient stay or partial hospitalization must be preauthorized by the contracted behavioral health management company. SECTION CM – CLINICAL MANAGEMENT‌ A wide range of Clinical Management Programs are available under this coverage with Keystone. These Clinical Management Programs are intended to provide a personal touch to the administration of the benefits available under this coverage. Program goals are focused on providing members with the skills necessary to become more involved in the prevention, treatment and recovery processes related to their specific illness or injury. • Clinical Management Programs include: • Utilization Management (Preauthorization, Medical Claims Review); • Care Management (Concurrent Review, SmartSurgerysm Program, Discharge Outreach Call Program, Case Management); • Disease Management; • Maternity Management; • Quality Management; and • Health Education and Wellness (including 24-Hour Nurse Line and Nicotine Cessation Program). UTILIZATION MANAGEMENT‌ The Utilization Management Program is a primary resource for the identification of Members for timely and meaningful referral to other Clinical Management Programs and includes Preauthorization and Medical Claims Review. Both Preauthorization and Medical Claims Review use a Medical Necessity and/or Investigational review to determine whether services are covered benefits. Members who have questions regarding a utilization review can contact Customer Service Monday through Friday, 8:00 a.m. to 6:00 p.m. by calling the toll-free number on their ID card. If the question is about a specific utilization case or decision that cannot be answered by Customer Service, the Member’s call will be forwarded to the Utilization Management Department. After normal business hours, Members can still call this telephone number to leave a message. A Keystone Customer Service Representative will return their call the next business day. Medical Necessity Review This coverage with Keystone provides benefits only for services Keystone or its designee determines to be Medically Necessary as defined in Section DE - Definitions, except in limited circumstances as required by law. When Preauthorization is required, Medical Necessity of benefits is determined by Keystone or its designee prior to the service being rendered. However, when Preauthorization is not required, services still undergo a Medical Necessity review and must still be considered Medically Necessary to be eligible for Coverage as a benefit. A Participating Provider will accept Keystone’s determination of Medical Necessity. The Member will not be billed by a Participating Provider for services that Keystone determines are not Medically Necessary. A Participating Provider is required to obtain Preauthorization for those services requiring Preauthorization. Not all treatment and services recommended by a provider will meet Xxxxxxxx’s definition of Medically Necessary as defined in this Agreement. The Member or the provider may contact Keystone’s Clinical Management Department to determine whether a service is Medically Necessary. Keystone does not reward individuals or practitioners for issuing denials of coverage or provide financial incentives of any kind to individuals to encourage decisions that result in underutilization. Investigational Treatment Review This coverage with Keystone does not include services Keystone determines to be Investigational Services as defined in Section DE - Definitions of this Agreement. However, Xxxxxxxx recognizes that situations occur when a Member elects to pursue Investigational Services at the Member’s own expense. If the Member receives a service Keystone considers to be Investigational Services, the Member is solely responsible for payment of these services and the non-covered amount will not be applied to the Out-of-Pocket Maximum or Deductible, if applicable. A Member or a provider may contact Keystone to determine whether Keystone considers a service to be Investigational Services. Preauthorization Preauthorization is a process for evaluating requests for coverage of services prior to the delivery of care. The general purpose of the Preauthorization program is to facilitate the receipt by Members of: • Medically appropriate treatment to meet individual needs; • Care provided by Participating Providers delivered in an efficient and effective manner; and • Maximum available benefits, resources, and coverage. Participating Providers are responsible for obtaining required Preauthorizations. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for information on this program. Members should carefully review this attachment to determine whether services they wish to receive must be preauthorized by Xxxxxxxx. This listing may be updated periodically. A Preauthorization decision is generally issued within two (2) business days of receiving all necessary information for non-urgent requests. Medical Claims Review Xxxxxxxx’s clinicians conduct Medical Claims Review retrospectively through the review of medical records to determine whether the care and services provided and submitted for payment were medically necessary. Retrospective review is performed when Keystone receives a claim for payment for services that have already been provided. Claims that require retrospective review include, but are not limited to, claims incurred: • under coverage that does not include the preauthorization program; • in situations such as an emergency when securing an authorization within required time frames is not practical or possible; • for services that are potentially investigational or cosmetic in nature; or • for services that have not complied with preauthorization requirements. A retrospective review decision is generally issued within thirty (30) calendar days of receiving all necessary information. If a retrospective review finds a procedure to not be medically necessary, the Member may be liable for payment to the provider. CARE MANAGEMENT‌ The Care Management Program is a proactive Clinical Management Program designed for members with acute or complex medical needs who could benefit from additional support with coordinating their care. The Care Management Program includes: • Concurrent Review Program (including Discharge Planning); • SmartSurgery Program; • Discharge Outreach Call Program; and • Case Management Program. Concurrent Review Program The Concurrent Review Program includes Concurrent Review and Discharge Planning Concurrent Review Concurrent review is conducted by experienced Keystone Health Plan Central registered nurses and board- certified Physicians to evaluate and monitor the quality and appropriateness of initial and ongoing medical care provided in Inpatient settings (Acute Care Hospitals, Skilled Nursing Facilities, Inpatient Rehabilitation Hospitals, and Long-Term Acute Care Hospitals). In addition, the program is designed to facilitate identification and referral of Members to other Clinical Management Programs, such as Case Management and Disease Management; to identify potential quality of care issues; and to facilitate timely and appropriate discharge planning. A Concurrent Review decision is generally issued within one (1) day of receiving all necessary information. Discharge Planning Discharge planning is performed by Concurrent Review nurses who communicate with hospital staff, either in person or by telephone, to facilitate the delivery of post-discharge care at the level most appropriate to the patient’s condition. Discharge planning is also intended to promote the use of appropriate outpatient follow- up services to prevent avoidable complications and/or readmissions following inpatient confinement. SmartSurgery Program The SmartSurgery Program is for members scheduled to undergo selected elective surgical procedures. Prior to admission, a Keystone nurse may contact a member by telephone to discuss expectations regarding the upcoming Hospital stay, answer questions about scheduled procedures and address any other concerns regarding post-discharge care. The goal of the program is to promote a successful inpatient stay and facilitate a smooth recovery by encouraging preoperative education, proper coordination of care, and early discharge planning.

After Hours Services. Members who need medical services after normal hours should contact their PCP. The PCP’s answering service may take the Member’s call. If so, the answering service will contact the Member’s physician or the physician on call, who will contact the Member as soon as possible. After hours calls should be limited to medical problems requiring immediate attention. However, Members should not postpone calling their PCP’s office if they believe they need medical attention. • All continuing care as a result of Emergency Services must be provided or Referred by a Member’s Primary Care Physician or coordinated through Keystone’s Customer Service Department. • Some services must be Preauthorized by the HMO. Your Primary Care Physician or Participating Specialist works with the HMO's Care Management and Coordination team during the Preauthorization process. Services in this category include, but are not limited to: hospitalization; certain outpatient services; Skilled Nursing Facility services; and home health care. Services that require Preauthorization are noted in the attached Medical Care Preauthorization Schedule included with this Agreement. You have the right to appeal any decisions through the Member Complaint Appeal and Grievance Appeal Process. Instructions for the appeal will be described in the denial notifications. • All services must be received from Participating Providers within Keystone’s Limited Eligibility & Approved Service Area unless Preauthorized by Keystone, or except in cases requiring (1) Emergency Services or Urgent Care while outside Keystone’s Limited Eligibility & Service Area but within Keystone’s Approved Service Area; (2) Emergency Service, Urgent Care and follow-up care under the BlueCard Program while outside Keystone’s Approved Service Area; or (32) Guest Membership Benefits under the Away From Home Care Program while outside Keystone’s Approved Service Area. See Sections ER – Emergency, Urgent, Follow-up Care and GM – Away From Home Care Program Guest Membership Benefits. See also Section ACC - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Provider. Keystone Members may submit a written request for a written list of Participating Providers affiliated with participating Hospitals. Use your Provider Directory to find out more about the individual Providers and their qualifications, including Hospitals and Primary Care Physicians and Participating Specialists and their affiliated Hospitals. The directory also lists whether the Provider is accepting new patients. • To change Primary Care Physician, call Keystone’s Customer Service Department at the telephone number shown on the ID Card or go to Keystone’s website at xxxxxxxxxxxx.xxx. • Services Coordinated By The Contracted Behavioral Health Management Company. Members seeking mental health care and substance abuse services may obtain preauthorization for such services from the contracted behavioral health management company. The contracted behavioral health management company may refer members to participating providers for mental health care and substance abuse services and may also coordinate emergency care for such services. Members may contact the contracted behavioral health management company by calling 1-800- 000-0000 (TTY number: 7110-000-000-0000). Any such services which are not coordinated, or which exceed the services authorized by the member’s PCP or the contracted behavioral health management company, are not covered. For outpatient non-emergency services to be covered, the services must be received from a Participating Provider and must have a prior notification by the contracted behavioral health management company. If a need for inpatient care or partial hospitalization is identified, the inpatient stay or partial hospitalization must be preauthorized by the contracted behavioral health management company. SECTION CM – CLINICAL MANAGEMENT‌ A wide range of Clinical Management Programs are available under this coverage with Keystone. These Clinical Management Programs are intended to provide a personal touch to the administration of the benefits available under this coverage. Program goals are focused on providing members with the skills necessary to become more involved in the prevention, treatment and recovery processes related to their specific illness or injury. • Clinical Management Programs include: • Utilization Management (Preauthorization, Medical Claims Review); • Care Management (Concurrent Review, SmartSurgerysm Program, Discharge Outreach Call Program, Case Management); • Disease Management; • Maternity Management; • Quality Management; and • Health Education and Wellness (including 24-Hour Nurse Line and Nicotine Cessation Program). UTILIZATION MANAGEMENT‌ The Utilization Management Program is a primary resource for the identification of Members for timely and meaningful referral to other Clinical Management Programs and includes Preauthorization and Medical Claims Review. Both Preauthorization and Medical Claims Review use a Medical Necessity and/or Investigational review to determine whether services are covered benefits. Members who have questions regarding a utilization review can contact Customer Service Monday through Friday, 8:00 a.m. to 6:00 p.m. by calling the toll-free number on their ID card. If the question is about a specific utilization case or decision that cannot be answered by Customer Service, the Member’s call will be forwarded to the Utilization Management Department. After normal business hours, Members can still call this telephone number to leave a message. A Keystone Customer Service Representative will return their call the next business day. Medical Necessity Review This coverage with Keystone provides benefits only for services Keystone or its designee determines to be Medically Necessary as defined in Section DE - Definitions, except in limited circumstances as required by law. When Preauthorization is required, Medical Necessity of benefits is determined by Keystone or its designee prior to the service being rendered. However, when Preauthorization is not required, services still undergo a Medical Necessity review and must still be considered Medically Necessary to be eligible for Coverage as a benefit. A Participating Provider will accept Keystone’s determination of Medical Necessity. The Member will not be billed by a Participating Provider for services that Keystone determines are not Medically Necessary. A Participating Provider is required to obtain Preauthorization for those services requiring Preauthorization. Not all treatment and services recommended by a provider will meet Xxxxxxxx’s definition of Medically Necessary as defined in this Agreement. The Member or the provider may contact Keystone’s Clinical Management Department to determine whether a service is Medically Necessary. Keystone does not reward individuals or practitioners for issuing denials of coverage or provide financial incentives of any kind to individuals to encourage decisions that result in underutilization. Investigational Treatment Review This coverage with Keystone does not include services Keystone determines to be Investigational Services as defined in Section DE - Definitions of this Agreement. However, Xxxxxxxx recognizes that situations occur when a Member elects to pursue Investigational Services at the Member’s own expense. If the Member receives a service Keystone considers to be Investigational Services, the Member is solely responsible for payment of these services and the non-covered amount will not be applied to the Out-of-Pocket Maximum or Deductible, if applicable. A Member or a provider may contact Keystone to determine whether Keystone considers a service to be Investigational Services. Preauthorization Preauthorization is a process for evaluating requests for coverage of services prior to the delivery of care. The general purpose of the Preauthorization program is to facilitate the receipt by Members of: • Medically appropriate treatment to meet individual needs; • Care provided by Participating Providers delivered in an efficient and effective manner; and • Maximum available benefits, resources, and coverage. Participating Providers are responsible for obtaining required Preauthorizations. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for information on this program. Members should carefully review this attachment to determine whether services they wish to receive must be preauthorized by Xxxxxxxx. This listing may be updated periodically. A Preauthorization decision is generally issued within two (2) business days of receiving all necessary information for non-urgent requests. Medical Claims Review Xxxxxxxx’s clinicians conduct Medical Claims Review retrospectively through the review of medical records to determine whether the care and services provided and submitted for payment were medically necessary. Retrospective review is performed when Keystone receives a claim for payment for services that have already been provided. Claims that require retrospective review include, but are not limited to, claims incurred: • under coverage that does not include the preauthorization program; • in situations such as an emergency when securing an authorization within required time frames is not practical or possible; • for services that are potentially investigational or cosmetic in nature; or • for services that have not complied with preauthorization requirements. A retrospective review decision is generally issued within thirty (30) calendar days of receiving all necessary information. If a retrospective review finds a procedure to not be medically necessary, the Member may be liable for payment to the provider. CARE MANAGEMENT‌ The Care Management Program is a proactive Clinical Management Program designed for members with acute or complex medical needs who could benefit from additional support with coordinating their care. The Care Management Program includes: • Concurrent Review Program (including Discharge Planning); • SmartSurgery Program; • Discharge Outreach Call Program; and • Case Management Program. Concurrent Review Program The Concurrent Review Program includes Concurrent Review and Discharge Planning Concurrent Review Concurrent review is conducted by experienced Keystone Health Plan Central registered nurses and board- certified Physicians to evaluate and monitor the quality and appropriateness of initial and ongoing medical care provided in Inpatient settings (Acute Care Hospitals, Skilled Nursing Facilities, Inpatient Rehabilitation Hospitals, and Long-Term Acute Care Hospitals). In addition, the program is designed to facilitate identification and referral of Members to other Clinical Management Programs, such as Case Management and Disease Management; to identify potential quality of care issues; and to facilitate timely and appropriate discharge planning. A Concurrent Review decision is generally issued within one (1) day of receiving all necessary information. Discharge Planning Discharge planning is performed by Concurrent Review nurses who communicate with hospital staff, either in person or by telephone, to facilitate the delivery of post-discharge care at the level most appropriate to the patient’s condition. Discharge planning is also intended to promote the use of appropriate outpatient follow- up services to prevent avoidable complications and/or readmissions following inpatient confinement. SmartSurgery Program The SmartSurgery Program is for members scheduled to undergo selected elective surgical procedures. Prior to admission, a Keystone nurse may contact a member by telephone to discuss expectations regarding the upcoming Hospital stay, answer questions about scheduled procedures and address any other concerns regarding post-discharge care. The goal of the program is to promote a successful inpatient stay and facilitate a smooth recovery by encouraging preoperative education, proper coordination of care, and early discharge planning.

After Hours Services. Members who need medical services after normal hours should contact their PCP. The PCP’s answering service may take the Member’s call. If so, the answering service will contact the Member’s physician or the physician on call, who will contact the Member as soon as possible. After hours calls should be limited to medical problems requiring immediate attention. However, Members should not postpone calling their PCP’s office if they believe they need medical attention. • All continuing care as a result of Emergency Services must be provided or Referred by a Member’s Primary Care Physician or coordinated through Keystone’s Customer Service Department. • Some services must be Preauthorized by the HMO. Your Primary Care Physician or Participating Specialist works with the HMO's Care Management and Coordination team during the Preauthorization process. Services in this category include, but are not limited to: hospitalization; certain outpatient services; Skilled Nursing Facility services; and home health care. Services that require Preauthorization are noted in the attached Medical Care Preauthorization Schedule included with this Agreement. You have the right to appeal any decisions through the Member Complaint Appeal and Grievance Appeal Process. Instructions for the appeal will be described in the denial notifications. • All services must be received from Participating Providers within Keystone’s Limited Eligibility & Approved Service Area unless Preauthorized by Keystone, or except in cases requiring (1) Emergency Services or Urgent Care while outside Keystone’s Limited Eligibility & Service Area but within Keystone’s Approved Service Area; (2) Emergency Service, Urgent Care and follow-up care under the BlueCard Program while outside Keystone’s Approved Service Area; or (32) Guest Membership Benefits under the Away From Home Care Program while outside Keystone’s Approved Service Area. See Sections ER – Emergency, Urgent, Follow-up Care and GM – Away From Home Care Program Guest Membership Benefits. See also Section ACC - Access to Primary, Specialist and Hospital Care Network for procedures for obtaining Preauthorization for use of a Non-Participating Provider. Keystone Members may submit a written request for a written list of Participating Providers affiliated with participating Hospitals. Use your Provider Directory to find out more about the individual Providers and their qualifications, including Hospitals and Primary Care Physicians and Participating Specialists and their affiliated Hospitals. The directory also lists whether the Provider is accepting new patients. • To change Primary Care Physician, call Keystone’s Customer Service Department at the telephone number shown on the ID Card or go to Keystone’s website at xxxxxxxxxxxx.xxx. • Services Coordinated By The Contracted Behavioral Health Management Company. Members seeking mental health care and substance abuse services may obtain preauthorization for such services from the contracted behavioral health management company. The contracted behavioral health management company may refer members to participating providers for mental health care and substance abuse services and may also coordinate emergency care for such services. Members may contact the contracted behavioral health management company by calling 1-800- 000-0000 (TTY number: 711). Any such services which are not coordinated, or which exceed the services authorized by the member’s PCP or the contracted behavioral health management company, are not covered. For outpatient non-emergency services to be covered, the services must be received from a Participating Provider and must have a prior notification by the contracted behavioral health management company. If a need for inpatient care or partial hospitalization is identified, the inpatient stay or partial hospitalization must be preauthorized by the contracted behavioral health management company. SECTION CM – CLINICAL MANAGEMENT‌ A wide range of Clinical Management Programs are available under this coverage with Keystone. These Clinical Management Programs are intended to provide a personal touch to the administration of the benefits available under this coverage. Program goals are focused on providing members with the skills necessary to become more involved in the prevention, treatment and recovery processes related to their specific illness or injury. • Clinical Management Programs include: • Utilization Management (Preauthorization, Medical Claims Review); • Care Management (Concurrent Review, SmartSurgerysm Program, Discharge Outreach Call Program, Case Management); • Disease Management; • Maternity Management; • Quality Management; and • Health Education and Wellness (including 24-Hour Nurse Line and Nicotine Cessation Program). UTILIZATION MANAGEMENT‌ The Utilization Management Program is a primary resource for the identification of Members for timely and meaningful referral to other Clinical Management Programs and includes Preauthorization and Medical Claims Review. Both Preauthorization and Medical Claims Review use a Medical Necessity and/or Investigational review to determine whether services are covered benefits. Members who have questions regarding a utilization review can contact Customer Service Monday through Friday, 8:00 a.m. to 6:00 p.m. by calling the toll-free number on their ID card. If the question is about a specific utilization case or decision that cannot be answered by Customer Service, the Member’s call will be forwarded to the Utilization Management Department. After normal business hours, Members can still call this telephone number to leave a message. A Keystone Customer Service Representative will return their call the next business day. Medical Necessity Review This coverage with Keystone provides benefits only for services Keystone or its designee determines to be Medically Necessary as defined in Section DE - Definitions, except in limited circumstances as required by law. When Preauthorization is required, Medical Necessity of benefits is determined by Keystone or its designee prior to the service being rendered. However, when Preauthorization is not required, services still undergo a Medical Necessity review and must still be considered Medically Necessary to be eligible for Coverage as a benefit. A Participating Provider will accept Keystone’s determination of Medical Necessity. The Member will not be billed by a Participating Provider for services that Keystone determines are not Medically Necessary. A Participating Provider is required to obtain Preauthorization for those services requiring Preauthorization. Not all treatment and services recommended by a provider will meet Xxxxxxxx’s definition of Medically Necessary as defined in this Agreement. The Member or the provider may contact Keystone’s Clinical Management Department to determine whether a service is Medically Necessary. Keystone does not reward individuals or practitioners for issuing denials of coverage or provide financial incentives of any kind to individuals to encourage decisions that result in underutilization. Investigational Treatment Review This coverage with Keystone does not include services Keystone determines to be Investigational Services as defined in Section DE - Definitions of this Agreement. However, Xxxxxxxx recognizes that situations occur when a Member elects to pursue Investigational Services at the Member’s own expense. If the Member receives a service Keystone considers to be Investigational Services, the Member is solely responsible for payment of these services and the non-covered amount will not be applied to the Out-of-Pocket Maximum or Deductible, if applicable. A Member or a provider may contact Keystone to determine whether Keystone considers a service to be Investigational Services. Preauthorization Preauthorization is a process for evaluating requests for coverage of services prior to the delivery of care. The general purpose of the Preauthorization program is to facilitate the receipt by Members of: • Medically appropriate treatment to meet individual needs; • Care provided by Participating Providers delivered in an efficient and effective manner; and • Maximum available benefits, resources, and coverage. Participating Providers are responsible for obtaining required Preauthorizations. Members should refer to the Medical Care Preauthorization Schedule attachment to this Agreement for information on this program. Members should carefully review this attachment to determine whether services they wish to receive must be preauthorized by Xxxxxxxx. This listing may be updated periodically. A Preauthorization decision is generally issued within two (2) business days of receiving all necessary information for non-urgent requests. Medical Claims Review Xxxxxxxx’s clinicians conduct Medical Claims Review retrospectively through the review of medical records to determine whether the care and services provided and submitted for payment were medically necessary. Retrospective review is performed when Keystone receives a claim for payment for services that have already been provided. Claims that require retrospective review include, but are not limited to, claims incurred: • under coverage that does not include the preauthorization program; • in situations such as an emergency when securing an authorization within required time frames is not practical or possible; • for services that are potentially investigational or cosmetic in nature; or • for services that have not complied with preauthorization requirements. A retrospective review decision is generally issued within thirty (30) calendar days of receiving all necessary information. If a retrospective review finds a procedure to not be medically necessary, the Member may be liable for payment to the provider. CARE MANAGEMENT‌ The Care Management Program is a proactive Clinical Management Program designed for members with acute or complex medical needs who could benefit from additional support with coordinating their care. The Care Management Program includes: • Concurrent Review Program (including Discharge Planning); • SmartSurgery Program; • Discharge Outreach Call Program; and • Case Management Program. Concurrent Review Program The Concurrent Review Program includes Concurrent Review and Discharge Planning Concurrent Review Concurrent review is conducted by experienced Keystone Health Plan Central registered nurses and board- certified Physicians to evaluate and monitor the quality and appropriateness of initial and ongoing medical care provided in Inpatient settings (Acute Care Hospitals, Skilled Nursing Facilities, Inpatient Rehabilitation Hospitals, and Long-Term Acute Care Hospitals). In addition, the program is designed to facilitate identification and referral of Members to other Clinical Management Programs, such as Case Management and Disease Management; to identify potential quality of care issues; and to facilitate timely and appropriate discharge planning. A Concurrent Review decision is generally issued within one (1) day of receiving all necessary information. Discharge Planning Discharge planning is performed by Concurrent Review nurses who communicate with hospital staff, either in person or by telephone, to facilitate the delivery of post-discharge care at the level most appropriate to the patient’s condition. Discharge planning is also intended to promote the use of appropriate outpatient follow- up services to prevent avoidable complications and/or readmissions following inpatient confinement. SmartSurgery Program The SmartSurgery Program is for members scheduled to undergo selected elective surgical procedures. Prior to admission, a Keystone nurse may contact a member by telephone to discuss expectations regarding the upcoming Hospital stay, answer questions about scheduled procedures and address any other concerns regarding post-discharge care. The goal of the program is to promote a successful inpatient stay and facilitate a smooth recovery by encouraging preoperative education, proper coordination of care, and early discharge planning.