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As part of our ongoing effort to assure that claims for hospital services
provided to Independence members are paid in keeping with the Hospital
Agreement executed between your hospital(s) and Independence, we are
implementing a change to our review of inpatient admissions. Effective
immediately, requests for payment at the rate reflecting an inpatient
admission for certain conditions will be subject to a secondary review by an
Independence Medical Director after an initial review by Independence
utilization review nurses.
Secondary reviews may be required for conditions that are often
appropriately managed with observation as an outpatient so that inpatient
admission is avoided. Many times, the need for inpatient admission is not clear
upon presentation, and an initial workup and institution of treatment may
warrant ongoing ambulatory care, avoiding the need for inpatient admissions.
Examples of such conditions include, but are not limited to, the following:
- abdominal pain
- asthma
- chest pain
- dehydration
- syncope
- transient ischemic attack (TIA)
Independence utilization review nurses will review all clinical information
presented and organize it to allow for application of the relevant criteria set
by InterQual®, a product of McKesson, an independent company. The
case will then be referred to an Independence Medical Director for final review
and determination. Please note that claims for outpatient observation services
do not require a utilization review determination as a prerequisite for
payment. The Hospital Manual for Participating Hospitals, Ancillary
Facilities, and Ancillary Providers will be updated to reflect this new
review process.
If you have any questions, please call 1-800-ASK-BLUE and
say Authorizations.
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