Hospital Inpatient Services. All hospitalizations require prior authorization (except for maternity and Emergency admissions as specified). The Member must contact (or have the provider contact CareFirst) at least five (5) business days prior to an elective or scheduled admission to the hospital. If the admission cannot be scheduled in advance because it is not feasible to delay the admission for five (5) business days due to the Member’s medical condition, CareFirst must receive notification of the admission as soon as possible but in any event within forty-eight (48) hours following the beginning of the admission or by the end of the first business day following the beginning of the admission, whichever is later. Emergency Admissions CareFirst may not render an adverse decision solely because CareFirst was not notified of the emergency admission within the prescribed period of time after that admission if the Member’s condition prevented the hospital from determining the Member’s insurance status or CareFirst’s emergency admission requirements.
Hospital Inpatient Services. All hospitalizations (except for maternity admissions as specified) require prior authorization. The Member must contact CareFirst (or have the provider contact CareFirst) at least five (5) business days prior to an elective or scheduled admission to the hospital. If the admission cannot be scheduled in advance because it is not feasible to delay the admission for five (5) business days due to the Member's medical condition, CareFirst must receive notification of the admission as soon as possible but in any event within forty-eight (48) hours following the beginning of the admission or by the end of the first business day following the beginning of the admission, whichever is later. Note the following:
Hospital Inpatient Services. 1. The MCO will share responsibility for inpatient general hospital services with the BHP.
2. The MCO shall be responsible for management and payment of claims for inpatient general hospital services when the medical diagnosis is primary. The medical diagnosis is primary if both the Revenue Center Code and primary diagnosis are both medical.
3. The MCO shall also be responsible for professional services and other charges associated with primary medical diagnoses during a behavioral stay.
4. The MCO shall also be responsible for ancillary services associated with non-primary behavioral health diagnoses during a medical stay, as described in subsection a. of this section.
5. The MCO shall not be responsible for ancillary services that are included in the hospital's per diem inpatient behavioral health rate.
Hospital Inpatient Services. (1) ACUTE CARE When a Participating Provider obtains preauthorization and admits Members to a hospital for acute care, Contractor will cover: _ semi-private room and board; _ isolation, coronary or other special acute care units, when Medically Necessary; and _ Hospital Services and supplies necessary for treatment and furnished by Participating Hospital, such as operating and recovery rooms, blood and blood components, traction equipment and special diets. Coverage for take home prescription drugs following a period of hospitalization and dispensed by the hospital will be limited to a three-day supply. Referrals to a Non-Participating Hospital must be preauthorized by PacifiCare unless a medical emergency necessitates such admission. A preauthorized hospitalization in a Non-Participating Facility will be covered. In a medical emergency, benefits paid to a Non-Participating Facility will continue until the OMAP Member can be safely transported to one of PacifiCare's Participating Facilities for continued hospitalization. OMAP Members refusing transport to a Participating Facility when it is safe for them to transfer will forfeit continued benefits for that hospitalization and all concurrent Non-Participating Provider care.
(2) LICENSED NURSING FACILITY PROVIDING SKILLED CARE: As an alternative to hospitalization, the PacifiCare can authorize up to sixty (60) days per calendar year in a licensed nursing facility that provides skilled care. In order to be covered, the care must be Medically Necessary and preauthorized by the Primary Care Physician. PacifiCare does not provide benefits for routine nursing care, self-help or training, personal hygiene or custodial care. Nor does PacifiCare provide benefits for care in a licensed nursing facility providing skilled care in cases of senile deterioration, mental deficiency or retardation, and psychotic or psychoneurotic conditions.
Hospital Inpatient Services. All elective inpatient hospital admissions (except for maternity and emergency admissions) require prior authorization. The Network Provider must contact Evergreen Health at least five (5) business days prior to an elective or scheduled admission to the hospital. If the admission cannot be scheduled in advance because it is not feasible to delay the admission for five (5) business days due to the Member’s medical condition, Evergreen Health must receive notification of the admission as soon as possible but in any event within forty-eight
