Peach State Provider Office Manual - Peach State Health Plan ...

An observation may last up to a maximum of forty-eight (48) hours.In those instances that a member begins their hospitalization in an observation status and themember is upgraded to an inpatient admission, all incurred observation charges and services willbe rolled into the acute reimbursement rate, or as designated by the contractual arrangement withPeach State, and cannot be billed separately. It is the responsibility of the hospital to notifyPeach State of the inpatient admission.Providers should not substitute outpatient observation services for medically appropriate inpatienthospital admissions.UTILIZATION MANAGEMENT CRITERIAPeach State has adopted utilization review criteria developed by McKesson InterQual Products.InterQual appropriateness criteria are developed by specialists representing a national panel fromcommunity-based and academic practice. InterQual criteria cover medical and surgicaladmissions, outpatient procedures, referrals to specialists, and ancillary services. Criteria areestablished and periodically evaluated and updated with appropriate involvement from physicianmembers of the Peach State Utilization Management Committee. InterQual is utilized as ascreening guide and is not intended to be a substitute for practitioner judgment. Utilization reviewdecisions are made in accordance with currently accepted medical or healthcare practices, takinginto account special circumstances of each case that may require deviation from the norm stated inthe screening criteria. Criteria are used for the approval of medical necessity but not for the denialof services. The Medical Director reviews all potential denials of medical necessity decision.Providers may obtain the criteria used to make a specific decision by contacting the MedicalManagement Department at 1-800-704-1483.Appeals related to a medical necessity decision made during the authorization, pre-certification orconcurrent review process can be made orally or in writing to:Appeals/Grievance Department3200 Highlands Parkway SE, Ste 300Smyrna, GA 300821-800-704-1463Providers and members have the right to request a copy of the review criteria or benefit provisionutilized to make a denial decision. Copies of the criteria can be obtained by submitting yourrequest in writing to:Medical Management3200 Highlands Parkway, SE, Ste. 300Smyrna, GA 30082Attn: IQ CriteriaPhysicians can discuss denial decisions with the physician reviewer who made the decision bycalling the Medical Management Department at 1-800-704-1483, Monday - Friday, between thehours of 8am and 5:30 pm.SECOND OPINIONProvider Services1-866-874-063302/22/201137