Inpatient Hospital Pre-Admission Review Sample Clauses

Inpatient Hospital Pre-Admission Review. When the Member’s Medicare coverage is primary coverage to this CareFirst BlueChoice plan, prior authorization for inpatient hospital services will not be required. Coverage of inpatient hospital services is subject to the requirements for pre-admission review, concurrent review, and discharge planning for all covered hospitalizations. Such review and approval will determine: A. The need for hospitalization; B. The appropriateness of the approved hospital or facility requested; C. The approved length of confinement in accordance with CareFirst BlueChoice established criteria; and D. Additional aspects such as second surgical opinion and/or pre-admission testing requirements. SAMPLE Failure or refusal to comply with notice requirements and other CareFirst BlueChoice authorization and approval procedures may result in reduction of benefits or exclusion of services from coverage.
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Inpatient Hospital Pre-Admission Review. When the Member's Medicare coverage is primary coverage to this CareFirst BlueChoice plan, prior authorization for inpatient hospital services will not be required. Coverage of inpatient hospital services is subject to the requirements for pre- admission review, concurrent review and discharge planning for all covered hospitalizations. Such review and approval shall determine: A. The need for hospitalization; B. The appropriateness of the approved Hospital or facility requested; C. The approved length of confinement in accordance with CareFirst BlueChoice established criteria; and D. Additional aspects such as second surgical opinion and/or pre-admission testing requirements. Failure or refusal to comply with notice requirements and other CareFirst BlueChoice authorization and approval procedures may result in reduction of benefits or exclusion of services from coverage. Payment for Ancillary Services may not be denied solely based on the fact that the denial of the hospitalization day was appropriate. Instead a denial of inpatient Ancillary Services must be based on the Medical Necessity of the specific Ancillary Service. In determining the Medical Necessity of an Ancillary Service performed on a denied hospitalization day, consideration must be given to the necessity of providing the Ancillary Service in the acute setting for each day in question.
Sample 1

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