Hospitals and emergency care
Guidelines and protocol for emergency medical conditions and hospital readmissions
Emergency medical conditions and emergency room visits
Wellpoint does not require prior authorization for treatment of emergency medical conditions. In the event of an emergency, members may access emergency services 24/7.
In the event that the emergency room visit results in the member’s admission to the hospital, providers must contact Wellpoint the next business day following admission or post-stabilization. Wellpoint intake staff will verify eligibility and determine benefit coverage.
Wellpoint is available via fax at 855-402-6985 or Interactive Care Reviewer (ICR) via Availity to accept emergent admission notification. For full details regarding emergency room claims, emergency care and hospital stays, please refer to your provider manual.
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Inpatient medical admissions
Hospitals must notify the Utilization Management department of inpatient medical admissions within 24 hours of admission or by the next business day. If there is insufficient clinical information to determine medical necessity, the provider is contacted with a request for the clinical information reasonably necessary to make this determination. Evidence-based criteria are used to determine medical necessity and the appropriate level of care.
For full details regarding continued stay review and inpatient medical admissions, please refer to your provider manual.
Hospital readmissions
Wellpoint does not reimburse for readmission for a related condition within seven days of discharge from a previous hospital confinement, in accordance with the Bureau for Medical Services (BMS) policy for readmissions. Wellpoint may require medical records and review readmissions within 30 days of discharge to determine if the member was discharged early. Claims for readmissions within 30 days that are due to early discharge may be denied. This Wellpoint reimbursement policy is in line with the BMS reimbursement policy.
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