03/03/2020

Priority Health Update

Change to facility retrospective authorization review time frame

Effective May 1, 2020, contracted medical and psychiatric inpatient hospitals, long-term acute care hospitals (LTACH), acute rehabilitation facilities, skilled nursing facilities (SNF), and mental health and substance use disorder residential facilities will have up to 90 days past the date of admission to request retrospective authorization for medical necessity determinations. After 90 days, the facility must submit a Level I provider appeal.

Historically, facilities could submit retrospective authorization requests for up to 12 months following an admission date.

Prior authorization of admissions is required and should be requested before administering services. Retrospective review is allowed up to 90 days after admission when circumstances prevent prior authorization.

Which product lines does this affect?

All product lines, including commercial, Medicare and Medicaid plans.

What is a retrospective authorization review?

A retrospective authorization review is an initial request that occurs after a patient as discharged from a medical facility. The review is used to determine medical necessity or coverage under the health plan benefit.

Special thanks to our 

Priority Health Managed Care Committee Member

Flora Varga

from

Cancer, Hematology & Rheumatology Centers of West Michigan