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PROVIDER POLICIES & PROCEDURES

Patient Care and Utilization Management

GlobalHealth has developed a patient management program to assist in determining what healthcare services are covered and payable under the health plan and the extent of such coverage and payments. The program assists members in receiving the appropriate healthcare and maximizing coverage for those healthcare services. In the event of a denial, providers and members will be informed by letter of any unmet criteria, standards and guidelines, as well as the appeal process.

Our patient management staff uses nationally recognized guidelines and resources to guide the pre-service, concurrent and post-service review processes. Using information obtained from providers, patient management staff applies MCG Guidelines®, CMS National and Local Coverage Determinations and other nationally recognized criteria when conducting pre-service and concurrent reviews.

Pre-service Authorization

Unless otherwise stated, healthcare services, such as referrals for hospitalization and outpatient surgery, require preauthorization from GlobalHealth. If you do not obtain preauthorization, services will not be paid.

GlobalHealth does not require prior authorization for specialists office visits. Members will have direct access to set up an office visit appointment with a network specialist physician.

Certain services rendered or referred by specialist physicians will require prior authorizations. Services include, but are not limited to: surgery, physical therapy, cardiac rehabilitation, Part B drugs, and specialized diagnostic tests such as MRIs. These are only examples. Please refer to the plan Evidence of Coverage or call Provider Services if you have any questions about whether a service requires prior authorization.

Concurrent Review

GlobalHealth performs concurrent review from the day of admission through discharge to assure the medical necessity of each day, that services are provided at the appropriate level of care, and that necessary discharge arrangements have been made. Indications that a member might be transferred to a lower level of care or alternative treatment setting are discussed with the admitting physician. If a dispute occurs between the admitting physician and GlobalHealth policy, the GlobalHealth Medical Director is contacted to review the member’s clinical status and treatment plan.

Discharge Planning

Discharge planning begins at the time GlobalHealth is notified of an admission and continues throughout the discharge process and includes the coordination of a patient’s continued care needs both in and out of the inpatient setting. A comprehensive discharge plan includes assessment of needs, plan development, plan implementation and evaluation of effectiveness.

The admitting physician should facilitate discharge planning by documenting the anticipated discharge date, disposition (e.g., home, SNF, rehabilitation, etc.), and any post-discharge services the member may require. GlobalHealth’s UM staff will coordinate with the hospital case manager to arrange for any needed services. GlobalHealth’s participation in the discharge planning process will vary based on the individual patient’s circumstances and may occur by telephone or through on-site reviews.

Post-Service Review

The purpose of a post-service review is to retrospectively evaluate the services rendered, analyze potential quality and utilization issues and review all appeals of inpatient concurrent review decisions. The following information will be used for the retrospective review: ER summary, medical record(s) and discharge diagnosis. GlobalHealth’s effort to manage the services provided to members includes the retrospective review of claims submitted for payment and medical records submitted for potential quality and utilization concerns.