Retrospective Inpatient Hospital Reviews Sample Clauses

Retrospective Inpatient Hospital Reviews. The Contractor shall have the capability and established procedures to receive Retrospective review request for Inpatient and Outpatient services within sixty (60) days of the service date and conduct prepayment reviews. The Contractor shall ensure determinations for Retrospective Reviews are completed ninety-eight percent (98%) of the time within twenty (20) business days of receipt. The Contractor shall develop and maintain a Web-based, electronic review request system for Prior Authorization and prepayment review of inpatient medical/surgical/behavioral health services that allows for data input by the submitting providers. The Contractor’s system shall have the capability for automated criteria/rules-based certification system. The Contractor shall manually review each Prior Authorization and prepayment review request received that is not certified by the Contractor’s rules- based system, along with any required supporting documentation to support the need for inpatient medical/surgical services. a. The Contractor shall have the capability and established procedures for verbal consultation by the physician reviewer with the attending physician to obtain additional information when the documentation submitted does not clearly support medical necessity. b. The Contractor shall ensure that all cases (including reductions) not meeting medical necessity criteria for inpatient medical/surgical/behavioral health services are reviewed by medical directors duly licensed in Mississippi and in compliance with Miss. Code Xxx. § 41-83-31. At any point after an initial denial a physician who has had a denial may request a review by a reviewer of the same specialty for the case in question. The Contractor shall have the capability and established procedures for verbal and written notification to the requesting provider of a pended review and for informing the provider of the information needed along with a time frame for submission. The Contractor shall have the capability and established procedures for verbal and written notification to the requesting provider of a suspended review. Notification to providers of suspended reviews shall not exceed the following:
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Retrospective Inpatient Hospital Reviews. The Contractor shall have the capability and established procedures to receive Retrospective review request for Inpatient and Outpatient services within sixty (60) days of the service date and conduct prepayment reviews. The Contractor shall ensure determinations for Retrospective Reviews are completed ninety-eight percent (98%) of the time within twenty (20) business days of receipt. The Contractor shall develop and maintain a Web-based, electronic review request system for Prior Authorization and prepayment review of inpatient medical/surgical services that allows for data input by the submitting providers. The Contractor’s system shall have the capability for automated criteria/rules-based certification system. The Contractor shall manually review each Prior Authorization and prepayment review request received that is not certified by the Contractor’s rules- based system, along with any required supporting documentation to support the need for inpatient medical/surgical services. a. The Contractor shall have the capability and established procedures for verbal consultation by the physician reviewer with the attending physician to obtain additional information when the documentation submitted does not clearly support medical necessity. b. The Contractor shall ensure that all cases (including reductions) not meeting medical necessity criteria for inpatient medical/surgical services are reviewed by medical directors duly licensed in Mississippi and in compliance with Miss. Code Xxx. § 41-83-31. At any point after an initial denial a physician who has had a denial may request a review by a reviewer of the same specialty for the case in question. The Contractor shall have the capability and established procedures for verbal and written notification to the requesting provider of a pended review and for informing the provider of the information needed along with a time frame for submission. The Contractor shall have the capability and established procedures for verbal and written notification to the requesting provider of a suspended review. Notification to providers of suspended reviews shall not exceed the following: Emergency Admission Reviews Verbal Notification to Provider Within four (4) hours past due date for requested information Non-Emergency Admission Reviews Weekend and Holiday Admission Reviews Continued Stay Reviews Written Notification to Provider Within one (1) business day past due date for requested information Retrospective Inpatient Hospita...
Sample 1Sample 2Sample 3See All (4)
Retrospective Inpatient Hospital Reviews. The Contractor shall have the capability and established procedures to receive Retrospective Inpatient Hospital Review requests and conduct prepayment reviews as such conditions are identified. The Contractor shall ensure determinations for Retrospective Inpatient Hospital Reviews are completed ninety-eight percent (98%) of the time within twenty (20) business days of receipt. The Contractor shall develop and maintain a Web-based, electronic review request system for Prior Authorization and prepayment review of inpatient medical/surgical services that allows for data input by the submitting providers. The Contractor’s system shall have the capability for automated criteria/rules-based certification system. The Contractor shall manually review each Prior Authorization and prepayment review request received that is not certified by the Contractor’s rules- based system, along with any required supporting documentation to support the need for inpatient medical/surgical services. a. The Contractor shall have the capability and established procedures for verbal consultation by the physician reviewer with the attending physician to obtain additional information when the documentation submitted does not clearly support medical necessity. b. The Contractor shall ensure that all cases (including reductions) not meeting medical necessity criteria for inpatient medical/surgical services are reviewed by medical directors duly licensed in Mississippi and in compliance with Miss. Code Xxx. § 41-83-31. At any point after an initial denial a physician who has had a denial may request a review by a reviewer of the same specialty for the case in question. The Contractor shall have the capability and established procedures for verbal and written notification to the requesting provider of a pended review and for informing the provider of the information needed along with a time frame for submission. The Contractor shall have the capability and established procedures for verbal and written notification to the requesting provider of a suspended review. Notification to providers of suspended reviews shall not exceed the following: Urgent/Emergent Admission Reviews Verbal Notification to Provider Within four (4) hours past due date for requested information Non-Emergency Admission Reviews Written Notification to Provider Within one (1) business day past due date for requested information Weekend and Holiday Admission Reviews Continued Stay Reviews Retrospective Inpatient Hospital ...
Sample 1

Related to Retrospective Inpatient Hospital Reviews

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