Concurrent Care
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Defines when multiple providers' services are considered concurrent care for Institutional Special Needs Plan (ISNP) members and what services are not separately reimbursable while members are institutionalized; affects providers furnishing care to Longevity Health Plan of Colorado ISNP members.
No material clinical or coverage changes in this revision.
Concurrent Care — Coverage Criteria
Services considered concurrent care
Specific services considered concurrent care (not separately covered) for institutionalized ISNP members unless prior authorized or upon discharge:
Remote physiologic monitoring and Advanced Primary Care components are duplicative of facility/Plan services and not covered while institutionalized; remote monitoring and APC may be covered after discharge subject to prior authorization; physiatry requires additional clinical review (referral or prior authorization) to be considered.
The Plan excludes remote physiologic monitoring (remote patient monitoring) for members while they are institutionalized in ISNP settings because facility staff provide vital sign monitoring and the facility maintains 24-hour nursing access, making external RPM duplicative. RPM may be considered after the member discharges to the community, but such services are subject to prior authorization.
Palliative care is a specialized medical service focused on symptom and pain relief for serious illness. For ISNP members who are institutionalized, the Plan’s clinicians are expected to provide palliative services within their scope; therefore, additional palliative services delivered by external providers in the institutional setting are not separately covered.
When external providers render palliative services in addition to the Plan’s clinicians for institutionalized ISNP members, those services are considered not reasonable or medically necessary and will not be covered.
Provider Actions, Authorization & Documentation
Obtain prior authorization for RPM, APC post-discharge and for physiatry
Remote physiologic monitoring and Advanced Primary Care components may be covered only after the member discharges from the institutional setting to a community setting, and such services are subject to prior authorization. Physiatry also requires additional clinical review in the form of referral or prior authorization when requested while the member remains institutionalized.
- Remote physiologic monitoring: covered only post-discharge and requires prior authorization (facility nursing provides vital sign monitoring while institutionalized).
- Advanced Primary Care components (PCM, TCM, CCM): may be covered only after discharge and require prior authorization.
- Physiatry: requires additional clinical review via referral or prior authorization to support coverage while institutionalized.
Document active roles and medical necessity for each concurrent provider
Providers must document an active, necessary clinical role for each concurrent provider; documentation must show that services from each provider are reasonable and necessary and that more than one attending physician is warranted by the patient's condition.
- Clinical records must justify why multiple attending physicians are required rather than consultative services.
- If services of one physician are not warranted, payment may be made only for the other physician(s).
Clinical role justification — document active role for each concurrent provider
Clinical records must explicitly support that each concurrent provider is required to play an active role in the patient's treatment and that the services provided by each are reasonable and necessary.
- Include clinical rationale showing distinct, necessary contributions from each provider (e.g., separate medical conditions requiring different specialties).
- If documentation shows one physician's services are not warranted, payment may be limited to the warranted physician(s).
Refer or prior-authorize physiatry for institutionalized members
When physiatry services are requested for institutionalized ISNP members, obtain a referral or prior authorization because physiatry will not be covered without additional clinical review to support the specialty care.
- Submit clinical documentation or referral demonstrating need for physiatry beyond Plan-provided primary care and facility therapy services.
- Do not assume automatic coverage while the member is institutionalized; prior authorization or referral is required for consideration.
Payment limited to one physician when multiple attendings are not warranted
If multiple physicians of the same specialty render services but the patient’s condition does not warrant multiple attendings, payment may be made for only one physician’s services.
- Assess whether more than one attending physician is clinically necessary; if not, expect payment limitation to a single physician.
- This rule applies especially when two providers in the same specialty could provide the needed care.
Do not bill RPM during institutionalization — duplication and denial risk
Do not bill for remote physiologic monitoring while the member is institutionalized; these services duplicate facility nursing vital sign monitoring and are not covered while institutionalized.
- RPM may be considered only after discharge to the community and requires prior authorization.
- Billing for RPM during institutionalization risks denial as duplicative of facility nursing services and 24-hour nursing access.
APC components billed externally while institutionalized are concurrent care — prior authorization post-discharge
Advanced Primary Care components (Principal Care Management, Transitional Care Management, Chronic Care Management) provided by external providers while the member is enrolled in the ISNP and institutionalized are considered concurrent care and may not be separately covered; these services may be covered only after discharge and require prior authorization.
- APC components are part of the Plan's Model of Care and are delivered by Plan clinicians; external billing for the same services while institutionalized risks denial.
- If member discharges to the community, APC services may be covered with prior authorization.
Do not provide/bill additional palliative care for institutionalized members
Palliative care rendered in addition to Plan clinicians for institutionalized ISNP members is not reasonable or medically necessary and is not covered.
- Do not bill separate palliative care services in addition to services provided by Plan clinicians for institutionalized members.
- Providers rendering additional palliative services to institutionalized members should expect denials as not reasonable/medically necessary.
Definitions
Background
Concurrent care refers to situations in which more than one provider delivers services beyond a consultative role during the same period. Coverage for concurrent services requires that each provider play an active, necessary role in the patient’s treatment and that the services from each be reasonable and necessary. If the patient’s condition does not warrant services from multiple attendings, payment may be limited to the single provider whose services are appropriate.
Discharge & Post-Institutional Coverage
Services such as remote physiologic monitoring and Advanced Primary Care components (Principal Care Management, Transitional Care Management, Chronic Care Management) may become eligible for coverage only after the member discharges from the SNF or residential setting to the community; in those cases coverage is subject to prior authorization.
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