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Inpatient timely notification requirements


To comply with our inpatient timely notification requirements, be sure to notify us of hospital admissions within one business day.* Also note:
 

  • You must precertify maternity or newborn confinement if the stay exceeds the standard three days or less for vaginal or five days or less for cesarean.
  • You have to contact us if notification is late or if you’ve discharged the patient.


Extenuating situations
 

There may be reasons why patients can’t provide coverage information. Note the following guidelines, regarding how we handle extenuating situations:

  • If you notify us within 14 days after the patient’s discharge, we’ll make a decision based on the information we have.
  • If you notify us after 14 days from the patient’s discharge, we’ll note your contact. The situation might require inquiries and/or documentation. Examples of supporting evidence we may consider upon appeal include**:
    • ID card/eligible information was obtained before or during admission.
    • Facility face/demographics sheet (contains patient demographic information).
    • Records confirming contact with another carrier before/during admission.


*Pennsylvania and Indiana allow alternative timeframes for notification.


**We’ll review supporting evidence, along with all available information, to make a correct appeal decision.