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Elizabeth M. Whitehorn, Director

Provider Notice issued 08/30/13

Utilization Review Changes Effective for Admissions On and After October 1, 2013

To:​ Participating Hospitals – Chief Executive Officers, Chief Financial Officers, Patient Accounts Managers, and Utilization Review Departments​
Date:​ August 30, 2013​
Re:​ Utilization Review Changes Effective for Admissions On and After October 1, 2013​

The department, in conjunction with its Quality Improvement Organization (QIO), eQHealth Solutions, Inc., has prepared a new listing of admitting diagnosis codes that will be subject to retrospective prepayment review.   

New Attachment E for One-Day Stays

Effective with admissions on and after October 1, 2013, the department will employ a new utilization review code list referred to as Attachment E. Attachment E contains admitting diagnosis codes that will prompt retrospective prepayment review by eQHealth Solutions, Inc., if the following claim parameters are met:

  • The claim is for general inpatient services only (category of service 20).

  • The claim is for a one-day stay when the patient admission and discharge (including transfers) occur on the same calendar date, or the discharge (including transfers) occurs on the day following admission.

  • The claim may be either DRG or per diem reimbursed.

One-day stay claims that are coded with a patient discharge status identifying that the patient expired are excluded from this review requirement. Claims submitted by hospitals enrolled as Long Term Acute Care (LTAC) hospitals are also excluded, as all LTAC claims are subject to mandatory concurrent review.

A claim meeting the review criteria will suspend for F76 – Susp for Review/One Day Stay. Once reviewed and approved by eQHealth Solutions, Inc., the claim will be released for adjudication. If a claim is reviewed and denied by eQHealth Solutions, Inc., the claim will reject for P68 – Prepay Rev Rej/One Day Stay. Refer to the hospital’s eQHealth Solutions, Inc. advisory notice regarding the denial. 

There are no changes at this time to Attachments A, B, C, or D. Attachments A through E can be downloaded from the department’s Peer Review Organization (PRO)/Quality Improvement Organization (QIO) website.  

Any questions regarding the review process may be directed to eQHealth Solutions, Inc. at the toll-free Helpline at 1-800-418-4045. Any questions regarding this notice may be directed to the Bureau of Quality Management at 217-557-5438.

 

Theresa A. Eagleson, Administrator  

Division of Medical Programs