Dear Provider,
WellCare is implementing the following policy for Short Inpatient Hospital Stays effective on November 1, 2020.
Summary of Policy:
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
What does this mean for providers?
It is the policy of health plans affiliated with Centene Corporation® that inpatient hospital stays (vs. observation) of 2 days or less are medically necessary for one of the following indications:
Admission is for a procedure on the CMS Inpatient Only List, (addendum E found here.
Admission to an intermediate or intensive care unit level of care (including neonatal intensive care unit (NICU) considered medically necessary per a nationally-recognized clinical decision support tool;
Unexpected death during the admission;
Departure against medical advice from a medically necessary (per a nationally-recognized clinical decision support tool) inpatient stay;
Transferred from another facility, with a medically necessary (per a nationally-recognized clinical decision support tool) total length of stay greater than 2 days;
Election of hospice care in lieu of continued treatment in hospital.
To ensure consistency with the Department of Community Health’s requirement, InterQual Guidelines will be used as the review tool in conjunction with this clinical policy, standards of medical practice as determined by a licensed clinician, evidence-based guidelines, positions of leading national health professional organization and other available clinical information.
Note: The policy at the link below will provide background and references for medical record review.
To review the complete policy please visit Georgia Clinical Guidelines
We are here to help. If you need further information, please contact your Network Representative.
