Inpatient Hospital Notification and Authorization

Definitions

Admission: The time of birth at a hospital or other act that allows the member to officially enter a hospital to receive inpatient hospital services under the supervision of a physician who is a member of the medical staff.

Admitting Physician: The physician who orders the member’s admission to the hospital.

Authorization Number: The number PrimeWest Health issues that establishes that all or part of the inpatient hospital services are medically necessary.

Certification of Need for Care: Admitting physician or hospital providing services certifies the admission to the hospital in the medical record; it is dated and signed by a physician, physician assistant, or nurse practitioner.

Concurrent Review: A medical record review completed to determine medical necessity of inpatient hospital services while the member is in the hospital. The review consists of admission review, continued stay review, and, when appropriate, procedure review.

Continued Stay Review: A review and determination of the medical necessity of continuing inpatient hospital service to the member.

Diagnostic Categories: The diagnostic classifications established under MN Stat. sec. 256.969, subd. 2, containing one or more Diagnosis Related Groups (DRGs) under Medicare.

Diagnostic Category Validation: The process of comparing documentation in the medical record to the information submitted on the inpatient hospital billing claim to ascertain the accuracy of the information upon which the diagnostic category was assigned.

Expedited Service Authorization: A Service Authorization for use when a provider indicates or PrimeWest Health determines that following the standard time frame could seriously jeopardize the member’s health and/or safety.

Inpatient Hospital Service: A service furnished in the hospital and provided by or under the supervision of a physician after admission to a hospital and outpatient services provided by the same hospital that immediately preceded the admission.

Inpatient Service Authorization: The certification number indicating that, upon initial review, the member seems to qualify for an inpatient stay.

Medical Necessity: A health service that is consistent with the member’s diagnosis or condition and is:

1. Recognized as the prevailing medical community standard or current practice by the provider’s peer group; and
2. Rendered in response to a life-threatening condition or pain; or to treat an injury, illness, or infection; or to treat a condition that could result in physical or mental disability; or to care for the mother and child through the maternity period; or to achieve community standards for diagnosis or condition; or
3. Is a preventive health service as defined in MN Rules part 9505.0355.

Out-of-Area Hospital: A hospital located outside of PrimeWest Health’s network of providers.

Principal Diagnosis: The condition established, after study, to be responsible for causing the admission to the hospital for inpatient hospital services.

Principal Procedure: A procedure performed for definitive treatment of the principal diagnosis rather than one performed for diagnostic exploratory purposes or a procedure necessary to take care of a complication. When multiple procedures are performed for definitive treatment, the principal procedure is the procedure most closely related to the principal diagnosis.

Readmission: An admission that occurs within 15 days of a discharge, not including the day of discharge or the day of readmission. Retrospective review may be completed to determine if the admission and readmission are considered separate admissions, transfer admissions, or a readmission that is a continuation of the previous admission.

Retrospective Review: A review conducted after inpatient hospital services are provided to a member. The review is focused on validating the diagnostic category, verifying recertification (where applicable), and determining the medical necessity of the admission, the medical necessity of any inpatient hospital services provided, and if all medically necessary inpatient hospital services were provided.

Transfer: The movement of a member after admission from one facility directly to another facility with a different provider number, or to or from a unit of a hospital to another unit recognized as a rehabilitation distinct part by Medicare. Transfer also includes members who move to or from extended inpatient psychiatric services capacity under contract with the Minnesota Department of Human Services (DHS). Moving a member from a medical or surgical service to the acute psychiatric unit within the same hospital is not considered a transfer and must be billed as one continuous hospitalization.

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Updated_09/25/2020