Authorization is required on an inpatient stay; however, under limited circumstances and by request, the AmeriHealth Care Management and Coordination (CMC) team may extend review of a case after services have been provided in order to determine coverage or eligibility for payment. This process is called retrospective (or post-service) review, and it is not a guarantee that the inpatient stay will be authorized. These limited circumstances include: when a hospital/facility is unaware of a member's insurance coverage at the initiation of service. In this scenario, it is the responsibility of the hospital/facility to obtain authorization as soon as that information is obtained. if the hospital/facility discovers that a patient is an eligible AmeriHealth member after he or she is discharged but he or she was incorrectly classified under different insurance coverage. In this case, the hospital/facility must provide CMC with the admission "face sheet." if the patient is discharged prior to medical review being completed. If you are not certain whether authorization for an inpatient stay was obtained, please use the NaviNet^® web portal to verify the status of the authorization request prior to submitting a claim. To request a retrospective review, please adhere to the following processes: For emergency admissions. If you find that notification of an emergency admission was not given by the hospital to CMC, you can request a retrospective review through NaviNet for up to a year after the date of service. To do so, select ER Admission Notification from the Authorizations option in the Plan Transactions menu. For elective admissions. If you find that authorization was not obtained for an elective admission, you can initiate a review by calling 1-800-275-2583 Monday through Friday, 8 a.m. to 6 p.m., and following the voice prompts. Note: Please do not send paper copies of the member?s complete medical record for an admission where authorization was not previously obtained. Medical records only need to be submitted in select cases and upon request. Once our CMC team has been notified of the request for retrospective review, we will contact the hospital/facility to request clinical information. In the case of hospitals/facilities for which we have remote access to medical records, we will attempt to obtain the clinical information on our own. Review of the case and notification of the determination will be made no later than 30 days from when we receive all supporting information that is necessary to perform the review. If the hospital/ facility fails to supply clinical information for retrospective review, we may issue an administrative denial of payment. Please also note the following: We will base our determination of medical necessity on the information that was available to the hospital/facility at the time of admission. The hospital/facility may not bill a member for services that are determined not to be medically necessary during the retrospective review process. If you have any questions about this process, please call your Network Coordinator or Hospital/Ancillary Services Coordinator.

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