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Medicaid
Acute Care Service Review
Certified to conduct utilization review in Connecticut and Rhode Island, Qualidigm reviews requests for acute care hospital services. Our staff nurses look at the type of care and services that hospitals or their physicians request and the appropriateness of the setting for needed care. These utilization review services also include requests for out-of-state inpatient hospitalizations or services, inpatient rehabilitation and transplant services.
Tools & Resources
FAQs
Is this new prepayment review process for patients admitted as of January 1, or for any client whose eligibility was granted as of January 1 regardless of when the service was actually delivered?
Qualidigm will review all non-eligible Medicaid and SAGA clients who were admitted and granted eligibility retroactively to cover the date of inpatient hospital admissions. (Hospitals were unable to receive authorization at time of admission because of lack of eligibility). Qualidigm will begin reviewing these cases effective January 1, 2007. The admission dates may be any time in the past.
Are clients who are active but in “spend down” included?
Spend down clients are not active Medicaid recipients and as such hospitals are unable to receive prior authorization for their inpatient hospital admissions. These spend down clients would therefore be included in this review.
Are the 5 and 10 days business or calendar days?
The 5-day and 10-day notification are business days.
How frequently will the Automated Eligibility Verification System (AVES) information be updated?
AEVS is updated in real time, i.e., - as soon as the regional eligibility worker updates the case.
Can the documents be faxed?
Yes, the UR review can be faxed to Qualidigm at 860-635-3628.
The fax must include:
- The completed form.
- A copy of the eligibility verification document or number.
- The up to five-day utilization review.
The UR review should include sufficient information for the review to be completed with minimal requirement for clarification of information or study results. This will allow for the expedited completion of the review and granting of authorization.
What if a client is admitted and thought to be Medicare Prime but later found tohave no Part A, only Part B?
This type of case will also be included in the new review process. Supportive documentation should be included to indicate that Medicare coverage determination was actually the issue.
What about commercial insurance and a similar process of the timing involved in identifying if Medicaid is also involved?
See question 6. Supportive documentation that there was no indication of Medicaid at the time of admission must be submitted.