TMPPM 2011 > Volume 1, General Information > Section 8: Managed Care > PCCM > PCCM Inpatient Authorization Process > Out-of-Network Inpatient Services

8.6.17.10 Out-of-Network Inpatient Services

Out-of-network hospitals may be reimbursed only for inpatient services provided to PCCM clients as the result of an emergency admission. Out-of-network facilities must notify the Inpatient Prior Authorization Department of a client admission within the next business day following the admission. Medical documentation must be submitted with notification to determine appropriateness for transfer to a contracted facility. Scheduled medical and surgical admissions or any nonemergent admission must be precertified indicating the reason why the patient must be admitted or transferred to an out-of-network facility (i.e., the services needed are not provided in a network facility, the patient had an emergent condition requiring admission while away from the SA).

A routine OB or newborn admission to an out of network facility does not require notification or prior authorization.

Nonroutine OB or newborn services require prior authorization within the next business day following the determination that the services are nonroutine.

Refer to: Subsection 8.6.17.7, "Obstetrical and Newborn Notification" in this section for the definition of routine and nonroutine OB or newborn services.

After a patient in an out-of-network hospital is stabilized, additional services are considered noncovered benefits. The out-of-network hospital may, however, request an exception to the stabilization policy by contacting the PCCM Inpatient Prior Authorization Department at 1-888-302-6167:

•The hospital must state the circumstances surrounding the emergency admission and provide an estimate of the additional number of days required until the patient is discharged.

•PCCM grants exceptions based on the information provided by the noncontracted hospital and issues an authorization for billing purposes if an exception is granted.

•Although in some cases the PCCM Inpatient Prior Authorization Department may require additional time to review the circumstances of the request for exception, it normally reviews the request and contacts the out-of-network hospital within 36 hours of its request. The Inpatient Prior Authorization Department will either provide the noncontracted hospital with an authorization or deny the exception request.

•Should a stabilization exception be denied, any inpatient services provided to the PCCM client at the out-of-network hospital will cease to be a covered benefit 24 hours after the hospital is notified.

Nonemergency inpatient admissions are not a covered benefit at out-of-network hospitals and are considered for reimbursement only if authorization has been received from the PCCM Inpatient Prior Authorization Department or the client would experience an undue burden traveling to a network hospital. In this case, a hardship exemption may be granted. This exemption permits reimbursement of a nonemergency admission at an out-of-network hospital.

To obtain a hardship exemption, the attending physician or designee must contact the PCCM Inpatient Prior Authorization Department at 1-888-302-6167 before any nonemergency admission to an out-of-network hospital and provide details to substantiate why the client would experience an undue burden traveling to a network hospital.

If the details substantiate undue burden, the PCCM Inpatient Prior Authorization Department will grant the exemption and issue an authorization. The physician can then admit the patient to the out-of-network hospital.

Note: Under no circumstances will authorization for an undue travel burden be granted after a patient has been admitted for a nonemergency condition to an out-of-network hospital.

PCPs referring clients to specialists should make the specialist aware of the PCCM non-contracted hospital admission policy.