With first-quarter 2021 already underway, and with so many variables in the long-term post-acute care (LTPAC) realm still uncertain as the coronavirus (COVID-19) pandemic rolls on, LTPAC organizations should be aware that different managed care plans are updating rules related to waivers and prior authorizations into 2021. These can impact your revenue cycle workflow process and should therefore be understood now.
Below are updates from five major payers, along with dates of expiration and links for additional information.
For all states, Aetna is temporarily applying the following changes for skilled nursing facility (SNF) admissions from acute hospitals, effective through February 28, 2021:
Initial precertification/prior authorization for admission from acute care hospitals to SNFs are waived for all commercial and Medicare Advantage (MA) Part C plans.
The SNFs will be required to notify Aetna of admissions within 48 hours. Providers may submit their request electronically through our provider. Providers can also submit their request by calling Aetna directly (refer to the back of the member’s ID cards for the correct telephone number).
The post-acute care facility would also be required to send medical records for concurrent review within three days of the initial admission.
The temporary suspension of prior authorization requirements for in-patient admissions to in-network SNFs ended on Jan. 31, 2021, except for select markets which are being communicated to directly. The temporary prior authorization suspensions apply to United Healthcare Medicare Advantage, Medicaid and individual and group market health plan members nationwide, where United Healthcare has health plans available. The suspensions were in effect from Dec. 18, 2020 through Jan. 31, 2021.
State variations and regulations may apply during this time. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s United Healthcare Community Plan website, if applicable.
Please note the following exceptions to the temporary provisions:
The provisions and effective dates noted here replace similar temporary prior authorization provisions for SNF admissions, facility transfers and COVID-19-related oxygen requests currently posted on UHCprovider.com/covid19 or communicated previously, unless the similar prior authorization provisions extended to higher levels of care or have expiration dates after Jan. 31, 2021.
Providers are not required to submit a new prior authorization when a member moves to a different yet similar site of care for the same service (e.g., hospital transfers or practice transfers).
State regulatory requirements, including end dates for specific state prior authorization relief requirements, still apply. Providers should check their state pages for more information.
For those areas where United Healthcare will begin offering new Individual Exchange health plans beginning Jan. 1, 2021, the temporary provisions applied from Jan. 1, 2021 through Jan. 31, 2021.
After Jan. 31, 2021, they may retrospectively review select services rendered during this time period. Admission notification is still required during this time, in alignment with the current protocol to support you in arranging post-admission care or other support services, if needed. In most cases, notification of inpatient admission is provided to United Healthcare by the hospital or facility through Link or an EDI 278N transmission that requires no intervention on the part of your staff.
In order to help facilitate freeing up bed space for COVID-19 patients, Cigna will allow emergent or urgent direct transfers for the expressed purpose of freeing up bed space for COVID-19 acute inpatient admissions to SNFs, acute rehabilitation facilities (ARs) and long-term acute care hospitals (LTACHs) without prior authorization until March 31st, 2021 for both commercial and Medicare businesses.
SNF, AR and LTACH facilities are responsible for notifying Cigna of admissions the next business day.
Coverage reviews for appropriate levels of care and medical necessity still apply to SNF, AR and LTACH admissions.
Concurrent review will start the next business day with no retrospective denials.
Per usual policy, Cigna does not require three days of inpatient care prior to transfer to an SNF. Please note that routine and non-emergent transfers to SNF, AR and LTACH continue to require precertification, and if a hospital is not at capacity and requiring the need to free up bed space for COVID-19, all of these transfers still require precertification.
“Like you, we are concerned with the unprecedented surge of COVID-19 cases in Arkansas, Colorado, Delaware, Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, New Hampshire, New Mexico, North Carolina, Ohio, Oklahoma, Pennsylvania, Texas, Utah, Virginia and West Virginia. We strive to understand the unique challenges different states face and determine how we can help. In response, Humana is suspending authorization requirements for SNFs for Medicare Advantage and commercial members in the entire states of Arkansas, Colorado, Delaware, Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, New Mexico, North Carolina, Ohio, Oklahoma, Texas, Utah, Virginia and West Virginia through Feb. 28, 2021. These suspended authorization requirements also apply to six Pennsylvania counties (Franklin, Philadelphia, Montgomery, Bucks, Chester and Delaware) and Hillsborough County in the state of New Hampshire.
“Except for the states of Delaware, Idaho and Utah, as well as Franklin County in Pennsylvania, NaviHealth will continue to work with skilled nursing facility-based teams on concurrent review for length of stay and appropriate level of care, including discharge planning. Please provide notification of admission within 24 hours to allow us to track our members’ progress and provide assistance with discharge planning. You will receive an approval when you submit the notification. This suspension applies to participating/in-network providers only.”
“Authorization suspension, as outlined herein, will continue through Feb. 28, 2021. This suspension applies to participating/in-network providers only. Please provide notification of admission within 24 hours to allow us to track our members’ progress. You will receive an approval when you submit the notification. No other services requiring prior authorization are included in this suspension. We are here to support you as you care for your Humana-covered patients, particularly during this difficult time. Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery. We will update you on policies and processes that affect your practices and organizations as this crisis evolves. If you have any questions about these new procedures, please contact your Humana representative.”
Correction to prior authorization requirements for transfers from acute inpatient hospitals (December 24 update) (as per an Anthem statement):
“On December 16, 2020, we communicated incorrectly that Medicare Advantage plans in Connecticut, Colorado, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin are waiving prior authorization requirements for acute IP hospitals to skilled nursing facilities, home health, acute rehabilitation, long-term acute care and swing beds. Correction: Medicare Advantage plans in Connecticut, Colorado, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin are only waiving prior authorization requirements for acute IP hospitals to skilled nursing facilities until January 15, 2021. Please contact the plan to determine authorization requirements for the other above-listed facilities.”
In summary, payer data is constantly changing. It’s important that your intake staff has the latest data in order to avoid denials and unnecessary appeals.
Learn More About Richter’s Outsourced Revenue Cycle Management Services
Do you have questions about updates to payer authorizations in 2021, or other LTPAC revenue cycle challenges? Learn more about Richter’s outsourced revenue cycle management services by contacting us here, or call 866-806-0799 to schedule a free consultation.
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