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7.5.15 PCCM Inpatient Authorization Process
7.5.15.1 Definitions
Authorization. The process of obtaining approval for the delivery of services.
Routine/Non-Emergent Condition. A symptom or condition that is neither acute nor severe and can be diagnosed and treated immediately, or that allows adequate time to schedule an office visit for a history, physical and/or diagnostic studies prior to diagnosis and treatment.
Urgent Condition. A symptom or condition that is not an emergency, but requires further diagnostic work-up and/or treatment within 24 hours to avoid a subsequent emergent situation.
Emergent/Emergency. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
• Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
•Serious impairment to bodily functions.
•Serious dysfunction to any bodily organ or part.
Emergency services means covered inpatient and outpatient services that are as follows:
•Furnished by a provider that is qualified to furnish these services under this title.
•Needed to evaluate or stabilize an emergency medical condition.
Poststabilization Services. Covered services, related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition, or to improve or resolve the enrollee's condition.
Observation Services. Services received within a hospital setting, which are "reasonable and necessary" to evaluate an outpatient condition or determine the need for possible admission to the hospital as an inpatient.
Notification. The process by which a facility informs PCCM that a client has been admitted as an inpatient to their facility on an urgent or emergent basis.
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