SCI Preauthorized Payment Authorization Form - Lovelace Health ...

The department adheres to the decision and notification standards consistent with NCQA, DOI and CMSregulations.Certain specified services and levels of care require a coverage determination andprecertification number as part of our program (Reference policy 2.03.02, Precertification).This process provides the opportunity for Health Services to determine benefit coveragestatus, assist with coordination of care needs and identification of catastrophic and chroniccases that may benefit from care coordination and case management. It also provides anopportunity to redirect care to more appropriate levels of care and credentialed providers.This includes use of the Company’s contracted Transplant Network centers for organ andtissue transplant evaluations and transplants. The Company does not require prospectivereview of emergency services (Reference policy 2.03.12, Emergency Services, and 2.03.30,Emergency Services – Medicare).B. Concurrent Management and Discharge Planning:Continuity of care is enhanced through pre and post admission and outpatient proceduretreatment plan review, evaluation of progress against the treatment plan and facilitating theplan of care through anticipation of care needs, identification of contracted providers andavailable benefits and communication with the treating providers.Inpatient continued stay review may be done telephonically, via fax or on-site at facilities,including but not limited to acute care facilities, skilled nursing facilities, long-term acute careand acute rehabilitation facilities.These processes include assisting the providers and members with coordinating treatmentplans to maximize services available within the member's health care benefit plan,coordination of care between third party payers, community resources, and the Company andto smoothly transition care across the continuum of inpatient and outpatient settings. Thisrequires effective communication with providers and members with a goal of improved healthoutcomes and enhanced member satisfaction.Milliman Care Guidelines is referenced to assess the level of care, treatment plan andprogress of member within the treatment plan. Additionally, the guidelines assist the staff toanticipate and work with the treatment team to plan for other care needs associated with theircondition or procedure and to recognize cases appropriate for further review by theCompany’s Medical Director.Case Review Rounds are conducted to review hospitalized members, and members open toCase Management, to identify possible care alternatives and to identify opportunities toimprove timing and access to covered services. Case Review Rounds participation includesthe Medical Directors, Behavioral Health Associate Medical Director, Directors, Managers,nurses, social workers and other disciplines as needed. Continued inpatient cases receive