Currentharvard pilgrim health carePolicy N/A

Elective Admission Notification

This document governs notification requirements and procedures hospitals and providers must follow when scheduling inpatient elective services for Harvard Pilgrim members; it affects hospitals, admitting providers, and other servicing providers for members except those on specified Choice/Choice Plus products.

Policy Summary

Payerharvard pilgrim health care

PolicyElective Admission Notification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionHospitals must notify Harvard Pilgrim at least one week before a scheduled inpatient elective service; some services require prior authorization and will pend for clinical review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

at least 1 weekrequired advance notification timeframe

800-232-0816fax number for notifications

800-708-4414Provider Service Center / phone

HPHConnect or NEHENelectronic submission channels

InterQualused to review inpatient elective services

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Elective Admission Notification Criteria

Notification and review requirements for elective inpatient services

Notification is required for elective inpatient services and such services will be reviewed using InterQual criteria to determine the appropriate setting (e.g., inpatient vs observation or surgical day care).

Notification must be made by the servicing provider (e.g., the hospital); the hospital, the member's PCP, or specialist may submit notification. The servicing provider should confirm that notification was made; failure to notify may result in a coverage denial.

Timing: Notification is required at least one week before the admission or date of service. If bed/operating room time becomes available with less than one week's notice, Harvard Pilgrim will attempt to expedite review to accommodate the shorter timeframe.

Required information: The notification must include the member's name and Harvard Pilgrim identification number; requesting and admitting provider names and NPIs; hospital name, location and NPI; diagnosis and clinical information; service requested (admission, procedure, etc.); CPT code(s) appropriate to the type of admission (medical or surgical); and admission date. All requests must be submitted with a valid NPI for the requesting and servicing providers.

CPT codes: Appropriate surgical CPT code(s) consistent with the surgical service are required and CPT code(s) appropriate to the type of admission (medical or surgical) must be included with the notification.

Notification channels: Elective admissions must be communicated through the available channels (e.g., HPHConnect or other designated submission methods).

Notification changes: Harvard Pilgrim must be notified of any change to the original notification, such as a change in date of service or a change in the type of service (for example, inpatient admission following observation or surgical day care).

Prior authorization: Some elective procedures/services require prior authorization; services that require authorization will pend for clinical review per the Authorization Policy.

CPT / Procedure Coding Requirements

CPT code requirementCPT

Appropriate surgical CPT code(s) must be included consistent with the surgical service; CPT code(s) appropriate to the type of admission (medical or surgical) are required.

Provider Notification and Response Procedures

Prior Authorization

Notification and prior authorization

Hospitals must notify Harvard Pilgrim when a member is scheduled for an inpatient elective service; some elective procedures/services require prior authorization and services that require authorization will pend for clinical review.

Notify at least one week before the admission or date of service (per notification timeframe).
Include required notification elements such as member name and identification, servicing provider NPI, diagnosis, requested service, CPT code(s), and admission date.

Documentation Required

Response timing

An immediate online confirmation of receipt is available; for fax submissions Harvard Pilgrim will update the system and return a fax or telephone confirmation within two business days. Services and elective admissions that require authorization will pend for clinical review.

Online submissions receive instant confirmation of receipt.

Key Definitions

inv-05: Elective Admission — Elective admission: an inpatient scheduled service that requires advance notification and may require prior authorization; reviewed using...

DefinitionElective admission: an inpatient scheduled service that requires advance notification and may require prior authorization; reviewed using InterQual criteria to determine appropriateness of setting (inpatient vs observation or surgical day care).

ApplicabilityDoes not apply to members with Choice or Choice Plus products offered through Passport Connect unless otherwise specified.

Review standardInpatient elective services are reviewed using InterQual criteria; current criteria available via HPHConnect or by contacting Provider Service Center at 800-708-4414.

Authorization noteSome elective procedures/services require prior authorization; services requiring authorization will pend for clinical review.

inv-06: Servicing provider / Notification requirements — Servicing provider: the hospital or provider submitting notification; must confirm notification was made and include required elements su...