Dear Provider,
WellCare is implementing the following policy for Short Inpatient Hospital Stays effective on October 1, 2020.
Summary of Policy:
La atención de observación es un conjunto bien definido de servicios específicos y clínicamente apropiados que abarcan el tratamiento, la evaluación y la reevaluación continuos a corto plazo antes de decidir si los pacientes necesitarán tratamiento adicional como pacientes hospitalizados o si pueden ser dados de alta del 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.
Note: The policy at the link below will provide background and references for medical record review.
To review the complete policy please visit https://www.wellcare.com/providers, select your state, then select Clinical Guidelines.
We are here to help. If you need further information, please contact your Network Representative.
