About Our Hospitalization Procedures for Members
We follow a review process for all emergency, elective, and scheduled hospital admissions.
Hospital Admission or Observation Status
Members are covered for life-threatening urgent and emergency care at any time in any facility. If any member requires observation or hospital admission, notify us within 24-48 hours of admission to receive consideration of SWHP coverage for the stay.
Call our Health Services Department at 1-254-298-3088 or 1-888-316-7947 Monday through Friday, 8 a.m. to 5 p.m.
Call our Health Services Department at 1-254-724-2111 after-hours, weekends, and holidays
When calling, have the following ready:
- • Member Name or membership number from SWHP Card
- • Day and time of admission or observation
- • Route of admission (ER, urgent, scheduled clinic admit)
- • Facility name and telephone number
- • Admitting or attending physician or provider
- • Telephone number for physician(s), or utilization review (U.R.) department
- • Admitting diagnosis
- • Scheduled or performed procedure(s)
Our Health Services Department (HSD) staff provides a confirmation number for billing purposes to the facility. This indicates that admission or observation has been called in within the authorized time frame. This is not an authorization for payment. You’ll be provided member benefits and approved length-of-stay (LOS). The HSD Utilization Management Clinician may need to obtain a report from the physician, utilization review, or case management department of the facility prior to determining SWHP coverage.
All elective and scheduled admissions for selected procedures must be pre-approved by SWHP Medical Director(s) through the appropriate SWHP Authorization Form.
Concurrent and Continued Stay Review
HSD reviews each hospitalization from the time of patient admission or observation through discharge and follow-up care. Each hospitalization day must meet InterQual® and/or SWHP internally-developed criteria of medical necessity, as determined by Plan Medical Director(s). The surgical patient must be admitted on the day of surgery unless specific medical justification for earlier admission is provided and approved by the Plan Medical Director(s). If we do not authorize an extension of hospital days based on submitted medical justification, those days will not be paid.
Retrospective (Post-Service) Review
It is noted that the majority of determinations made by SWHP are related to benefit coverage interpretations according to the Evidence of Coverage (EOC) and/or Standard Plan Document (SPD) and do not involve issues of medical necessity or appropriateness. Other decisions about medical necessity or appropriateness are made by the SWHP Medical Director(s) with input from the treating clinical Practitioners as appropriate. SWHP benefit determinations are related to payment for care or services based upon input from the Practitioner/Provider and according to the terms of the benefit contract.
HSD, delegated reviewers, or SWHP Medical Nurse Auditor(s) conduct Retrospective (Post-Service) reviews on cases not reviewed during the inpatient or concurrent review process. Cases may be missed due to the type or frequency of test or procedure when medical records were unavailable or the patient was admitted and discharged from a facility or provider’s care before a report could be obtained or records reviewed (i.e., situations in which the case and/or medical records have never been reviewed by SWHP due to circumstances beyond our control).
This does not include subsequent review of services for which prospective or concurrent reviews were previously conducted. When retrospective (Post-Service) review is performed, the review is based on written screening criteria (InterQual® or internally-developed SWHP Screening Criteria) established and annually updated with appropriate involvement from physicians (practicing physicians) and other healthcare providers. The HSD, delegated reviewer, or Medical Nurse Auditor reviews any potential issues regarding medical necessity or appropriateness with the Plan Medical Directors(s). No medical necessity denials are issued without Medical Director review and approval. If any denial is issued, appeal rights are provided to both the Member and the Practitioner or Provider.
Some retrospective reviews may be conducted to collect data for health or medical care evaluation studies. These are not related to the payment of claims.
For information or clarification, contact our Health Services Department at 1-254-298-3088 or1-888-316-7947.