ADVISORY NOTICE: AUTHORIZATION REQUESTS FOR POST-STABILIZATION CARE
July 2, 2024 9:00 amDear Provider Members,
Our office has been actively pursuing the resolution of claims on your behalf for post-stabilization care and services that we believe have been improperly denied by health plans. We have escalated our concerns to the Department of Managed Health Care (DMHC). We are now providing you with some guidance following the DMHC’s recent release of the All Points Letter (APL) 24-012. We hope that the following information will be of use to your organization.
DISCLAIMER: The intent of ERN is to present accurate and authoritative information to the subject matter covered. It is presented with the understanding that ERN is not engaged in the rendition of legal advice. Providers should consult with their legal counsel for application of the DMHC APL and the use of our guidance prior to making any changes based on the information presented here, including how you notify plans for authorization requests or how you document such requests.
The DMHC has taken the position that both contracted and noncontracted hospitals must make contact via telephone call in order to trigger the 30-minute response. ERN recommends that you continue to follow your existing workflow (e.g., fax notification) AND make 1 successful phone call to the plan (your hospital representative has to make a verbal request for authorization with a plan representative).**
In recent discussions with the DMHC (confirmed by the DMHC’s new APL), we have been advised that contact made to the patient’s health care service plan, or the health plan’s contracting medical provider, for authorization to provide post-stabilization care, must fulfill two requirements:
I. Requests for authorization to provide post-stabilization care and services must be made via a telephone call; and
II. The telephone call requesting authorization must be made:
a. Per the instructions on the patient’s health plan member card, or
b. [Preferred Method] Using the health plan’s designated 24/7 number to obtain post-stabilization authorization, which may also be found on the DMHC’s website under “Printable Notices” here: http://wpso.dmhc.ca.gov/hpsearch/postcontact.aspx
Importantly, the DMHC has advised that contacting the health plan, or its contracting medical provider, in some other way (e.g., email, facsimile, calling a different phone number) will NOT trigger the requirement for the plan to respond within 30 minutes and will NOT trigger the plan’s financial obligation to cover post-stabilization care and services or transfer of the patient.
In order to enforce violations for failure to respond timely to a request for authorization of post-stabilization services, the DMHC has requested providers clearly document the following in their hospital records:
1) When the patient was stabilized.
2) The telephone call requesting authorization for post-stabilization services, with all of the following information:
a. The full name of the health plan or IPA that was called;
b. The date and time the call was made;
c. The phone number that was called;
d. The name of the plan representative you spoke with and their title (e.g., CSR, medical director, nurse);
e. The call reference number;
f. What service was requested;
i. Clearly document that you requested authorization for inpatient admission.
ii. NOTE: Phone calls made to determine patient eligibility or verify insurance are not a request for authorization and are insufficient to trigger the plan’s requirement to respond within 30 minutes.
g. The health plan or IPA representative’s response, including the date and time you received or did not receive a timely response from the plan or its contracting medical provider.
i. Clearly document what specific services were authorized or denied (the number of days, inpatient vs. observation, etc.) or the exact response given if other than an authorization or authorization denial.
3) In cases where the patient is admitted for multiple days, providers should make and document a phone call requesting continued authorization at the end of each previously authorized period until the patient is discharged. For example, if the provider initially requests authorization to provide post-stabilization care upon admission from the ER and the health plan authorizes two days of service, the provider should make a call at the beginning of the third day requesting additional authorization and document the information in (a – g) above in the hospital record. This should continue until the patient is discharged.
NOTE: Although making more than one contact attempt is not legally required, as a practical matter and adjudicative fact, doing so until you reach a representative will significantly strengthen your position should a DMHC complaint filing be required, and will help you to increase your claim overturn rate. You should document each and every attempt to contact the health plan and/or IPA and include as much of the above information in (1 – 3) above as possible. In the event that you do not have the capability to make a telephone call and follow guidance per the contract or provider manual (if applicable), we recommend that you clearly document your inability to make two contact attempts. This will not count against you and actually will increase your claim’s overall standing.
Again, please be reminded that any other method of notification/authorization request will not trigger the 30-minute response from the plan, and the services you provide will not automatically be deemed authorized. For context, we are providing you an excerpt from our Statement of Position that we sent to the DMHC, which prompted the release of this APL:
We understand that, moving forward, the DMHC may be attempting to remedy the aforementioned issue through the two projects and release of a clarifying APL. In light of the DMHC’s proposed actions, we believe that this could adequately prevent plans from en gaging in manipulative behavior on contracts, willfully or negligently, that statutorily bar hospital providers from triggering the 30-minute response, thereby avoiding financial responsibility for post-stabilization services. In as much, we would like for the DMHC to consider including language in the final version of the APL that explicitly prohibits plans from providing different contact numbers or methods for authorization in contracts or provider manuals than those prescribed in subdivision (j) or (k) of California Health and Safety Code § 1262.8, less they be subject to criminal, civil, and administrative penalties.
Hospital Workflow & Plan of Action:
At this time, we suggest that you always notify health care service plans via (1) telephone call and (2) the method delineated in the contract or provider manual (if applicable) prior to providing post-stabilization care and services, and document both contact attempts per the DMHC guidance above. The [telephone call] number you contact should either be found on (1) the patient’s health member card, or (2) the DMHC website referenced above. When following a contact method from a contract or provider manual, please document your compliance with such contract or provider manual. For example, you may add a note in your hospital records stating the request for authorization of post-stabilization services was faxed to the plan per a specific section of the provider manual, or as instructed per a specific section of the contract (e.g., On (DATE), a facesheet of admission and request for authorization was faxed to 123-456 -7890 per section ___ of the contract).
Ideally, providers should make a phone call attempt to request authorization to provide post-stabilization services right after the patient has become stable and, generally, prior to admission (as patients are often stable prior to being admitted). In cases where the patient is admitted, but not yet stable, post-stabilization authorization should be requested as soon as the patient becomes stable. The time that you make contact with a plan representative via phone call is when that 30-minute timeframe triggers for the plan to respond (and subsequently become financially responsible if they fail to respond).
Please note, health plans may be able to deny services provided after stabilization and prior to the phone call request for authorization to provide post-stabilization services. If, for whatever reason, you are unable to make a phone call requesting authorization to provide post-stabilization services as soon as the patient becomes stable or prior to providing post-stabilization services, a phone call requesting authorization to provide post-stabilization services should be made as soon thereafter as possible in order to trigger the 30-minute timeframe and other requirements under California Health and Safety Code § 1262.8 and 28 CCR § 1300.71.4.
** ERN reached out to the DMHC for clarification on whether any of the below scenarios would constitute a successful call that would require the health plan to cover the post-stabilization services under California Health and Safety Code § 1262.8 and 28 CCR § 1300.71.4.
We can reasonably foresee that upon calling the health plan providers may have to:
- Leave a voicemail;
- Hang up due to prolonged wait times;
- Submit authorization requests via another method such as fax, as directed by plan reps;
- Call a number that is not a post-stabilization authorization line;
- Call a number after-hours that is not staffed after-hours;
Although the DMHC did not provide responses to the specific scenarios, the DMHC has reinforced the following:
Provider members should call the number on our public website and document the information noted below. The health plans are responsible for providing the DMHC with accurate information. If the contact information they provided the DMHC does not result in the health plan timely responding to provider requests for authorization of post-stabilization services or the transfer of the enrollee, the DMHC has a much stronger case to require the health plan(s) to cover the requested, post-stabilization services.
1) The health plan phone number called and where the phone number was obtained (e.g., the DMHC website, health plan’s annual filing to facilities).
2)The exact date and time of the call to the health plan and who they spoke with, whether they left a message, etc.
3) The specific post-stabilization services being requested. They should note this to the health plan representative or leave this information on a VM, if the health plan did not answer the initial call.
4) The date and time the provider received or did not receive a timely response from the health plan and the outcome of the call, if it was answered by a health plan representative.
Please let us know if you have any questions regarding the DMHC notification and documentation requirements above.
If you are outside of California, please check your state laws for any authorization waivers enacted during the COVID-19 PHE. Should you need assistance using those waivers to overturn claims for services rendered during the pandemic, please reach out to our office to discuss possible representation.
Respectfully,
Thitipong Mongkolrattanothai, J.D., M.P.H.
Compliance Auditor III
ERN/TRAF – The Reimbursement Advocacy Firm
Tel: (714) 820-6967 Fax: (714) 995-6901
Email: thitipongmongkolrattanothai@ernenterprises.org
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