Concurrent Review. Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that are not specifically stated in this Certificate. — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations, in the PHYSICIAN BENEFITS section of this Certi ficate. — Services or supplies that were received prior to the date your coverage be gan or after the date that your coverage was terminated. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply if you are a corporate officer of any business or enterprise, defined as a “small business” under paragraph (b), Section 3 or the Illinois Small Business Purchasing Act, as amended, and are employed by the cor poration and elect to withdraw yourself from the operation of the Illinois Workers' Compensation Act according to the provisions of the Act. — Services or supplies that are furnished to you by the local, state or federal government and services or supplies to the extent payments or benefits for such services or supplies are provided by or available from the local, state or federal government (for example, Medicare) whether or not those payments or benefits are received, exce...
Concurrent Review. The carrier shall be allowed to monitor the patient's care during hospitalization and to determine the length of appropriate hospitalization subject to reimbursement.
Concurrent Review. The INSURER will establish a program to review hospital admissions to guarantee adequacy and duration of stay.
Concurrent Review. Certification of a Hospital confinement admission will require concurrent review certification as to the continued need for confinement and length of stay.
Concurrent Review. (1) When We Authorize a Member’s Inpatient stay, We will Authorize his stay in the Hospital for a certain number of days. If the Member has not been discharged on or before the last Authorized day, and the Member needs additional days to be Authorized, the Member must make sure his Physician or Hospital contacts Our Care Management Department to request Concurrent Review for Authorization of additional days. This request for continued hospitalization must be made on or before the Member’s last Authorized day so We can review and respond to the request that day. If We Authorized the request, We will again Authorize a certain number of days, repeating this procedure until the Member is either discharged or the Member’s continued stay request is denied.
(2) If We do not receive a request for Authorization for continued stay on or before the Member’s last Authorized day, no days are approved past the last Authorized day, and no additional Benefits will be paid unless We receive and Authorize another request. If at any point in this Concurrent Review procedure a request for Authorization for continued stay is received and We determine that it is not Medically Necessary for the Member to receive continued hospitalization or hospitalization at the level of care requested, We will notify the Member and his Providers, in writing, that the request is denied and no additional days are Authorized.
(3) If We deny a Concurrent Review request or level of care request for Hospital Services, We will notify the Member, his Physician and the Hospital of the denial. If the Member elects to remain in the Hospital as an Inpatient thereafter, or at the same level of care, the Member will not be responsible for any charges unless he is notified of his financial responsibility by the Physician or Hospital in advance of incurring additional charges.
(4) Charges for non-authorized days in the Hospital that the Member must pay are considered non- covered and will not apply toward satisfying the Out-of-Pocket Amount.
Concurrent Review. A review conducted by the BH-MCO during a course of treatment to determine whether services should continue as prescribed or should be terminated, changed or altered.
Concurrent Review. Concurrent review processes address the appropriateness of an admission, continued stay setting and level of care as well as identify and prevent delays in care, clinical coverage decisions and discharge planning. United makes concurrent review determinations within one (1) working day of obtaining all necessary information. In the case of a determination to approve an extended stay or additional services, United will notify Provider by telephone and provide written or electronic confirmation to the Customer and Provider within one (1) working day thereafter. Written or electronic notification shall include the number of extended days or the next review date, the new total number of days or services approved, and the date of admission or initiation of services. In the case of an adverse determination, within 24 hours United will notify Provider by telephone and will provide written or electronic notification to the Customer and Provider within one (1) working day thereafter. The service will continue without liability to the Customer until the Customer has been notified of the determination.
Concurrent Review. 5.1. The DISTRICT shall coordinate a concurrent review of the status of the Regional Emergency Medical Services by REMSA with RENO, SPARKS WASHOE and FIRE prior to the approval of any modifications or Resolution to the Franchise Agreement and prior to any extension of the franchise period.
Concurrent Review. Concurrent review of inpatient admissions at participating and non-participating facilities is performed weekdays to determine the need for continued health care services. The review process is conducted utilizing Milliman Care Guidelines, LOCADTR
Concurrent Review. The review by The Plan of the Medical Necessity of the services that are in the process of being utilized. Concurrent Review includes, but is not limited to, continuing review of all inpatient care and outpatient procedures and services.
