December 15, 2020
Dear Provider,
WellCare is implementing the following policy for Short Inpatient Hospital Stays effective on February 1, 2021.
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/Kentucky/Providers/Clinical-Guidelines/CCGs/CCG-List.
We are here to help. If you need further information, please contact your Network Representative.
