LAC 40:I.2705. Pre-Admission Certification

Editor's Note: The telephone number for the Office of Workers' Compensation has been changed to (225) 342-7555. A. Pre-admission certification is the review and assessment of the medical necessity and appropriateness of non-emergency hospital admissions before hospitalization has occurred. The appropriateness of the site and the level of care is assessed along with the timing of the proposed admission. Actual payment for services is also contingent upon the carrier/self-insured employer's verification of: 1. claimant's entitlement to benefits at the time hospitalization actually occurs; and 2. statutory coverage for the care that is actually provided. B. Application for pre-admission certification should be made prior to admission to the hospital unless the admission to the hospital is for a compensable illness or bodily injury that occurs without warning and requires immediate inpatient treatment to prevent death, disability or serious impairment of patient function. In the event an inpatient admission is for treatment of such a medical emergency, notification must be made to the carrier/self-insured employer within 48 hours of admission. C. Louisiana Office of Worker’s Compensation Administration shall support both ICD-9 and ICD-10 coding formats for a period of time after the compliance date. Claims shall be accepted with ICD-9 codes for service dates or discharge dates prior to the compliance date for pre-authorized services and/or treatment or timely filing requirements. If an authorization is requested on or before the compliance date, and the date of service is on or after October 1, 2015, healthcare professionals must submit an ICD-10 code. If an authorization is requested after the compliance date, the ICD-10 code will be required. The pre-admission certification process follows the sequence below. 1. The physician, hospital, or claimant must initiate the pre-admission certification process by calling the carrier/self-insured employer. The reviewer will request the following information: a. claimant name; b. Social Security number; c. date of injury; d. claimant's address; e. sex; f. claimant's date of birth; g. name of hospital; h. hospital address; i. anticipated admission date; j. admitting diagnosis (to include ICD-10-CM codes);* k. expected length of stay; l. major procedures and related CPT/ICD-10-PCS codes;* m. plan of treatment; n. complications or other factors requiring the inpatient setting; o. medical justification for inpatient admission; p. is surgery anticipated? If yes, procedure; q. is general anesthesia required; r. admitting physician's name; s. admitting physician's address; t. admitting physician's phone number; u. admitting physician's Tax ID or Social Security number; and v. caller's name and number. *The provider will provide descriptive/narrative information and the reviewer, representing the carrier/self-insured employer, will provide the ICD-10-CM, ICD-10-PCS and/or CPT-4 codes. D. Pre-Admission Review Procedures 1. The carrier/self-insured employer must be able to administer a program where pre-admission certification review is initiated by the physician, hospital or claimant. Once the caller has made the first phone call to notify the carrier/self-insured employer of proposed hospitalization, the carrier/self-insured employer will follow through with phone calls and written confirmations to the claimant, physician and hospital. 2. Pre-admission certification review is primarily conducted by telephone during normal business hours (8 a.m. to 4:30 p.m. Central Time, Monday through Friday, excluding legal holidays) to assure quick responses. Written requests for pre-admission certification may be processed by the carrier/self-insured employer on a case by case basis. 3. The Office of Workers' Compensation Administration will require annual reports on all workers' compensation medical review activity. Automated software support for the review process is recommended in order to assure timely responses, uniform administration, and complete data gathering. 4. All non-emergency hospital admissions must be reviewed using nationally accepted criteria designed to assess the need for the acute level of care. The Appropriateness Evaluation Protocol (AEP) and the Intensity/Severity/Discharge (ISD) criteria are the two most prominent nationally accepted criteria for admissions. a. The AEP manual is available from: Utilization Management Assoc. 888 Worcester Street Wellesly, MA 02811 Phone: (617) 237-6822 b. The ISD manual is available from: InterQual 44 Lafayette North Hampton, NH 03862 Phone: (603) 964-7255 5. When the medical necessity of a proposed hospitalization is approved or certified, an expected length of stay is assigned. The length of stay is based on statistical norms developed by the Professional Activities Study (PAS) of the Commission on Professional and Hospital Activities, Southern Region. a. The PAS is available from: CPHA Publications 1968 Green Road Box 1809 Ann Arbor, MI 48106 Phone: (800) 521-6210 6.a. The carrier/self-insured employer shall use registered nurses for the initial review of recommended hospitalization. Registered nurses will use written criteria provided in Paragraph D.4 above to assess proposed hospitalizations. Physicians must review all questionable cases and make the carrier/self-insured employer decisions on all denials of certifications. b. Within five calendar days of receipt of the request, a response must be generated in writing as to whether or not the admission is approved or denied. Verbal response will be given within two working days from the time of the request followed by the written response. Copies of the written response will be sent to the attending physician, the hospital, and the claimant and must notify the parties of the right to appeal and the appeal process. Sample letters are enclosed as Clauses E.1.b.iii and iv. 7.a. An appeals process must be available for reconsideration of any denial decisions. If the admitting physician, hospital, or claimant desires to appeal a denial of an admission or continued stay request, the appeals process is initiated by contacting the carrier/self-insured employer by telephone or other immediate means following receipt of the denial. After the appeal request is received, it will be referred to the carrier/self-insured employer medical director or physician consultant in the appropriate specialty if required. The carrier/self-insured employer medical director or physician consultant will review the available information regarding the request and make a decision concerning the appeal within 48 hours of receipt/communication of the appeal. b. If the carrier/self-insured employer medical director decision is an approval of the appeal the admitting physician and hospital will be immediately notified via telephone and follow up by letter will be sent to the physician, claimant, and hospital. c. If the carrier/self-insured employer medical director's decision is a denial the carrier/self-insured employer will notify the admitting physician and hospital and will immediately submit in writing the denial and case documentation by fax to the director of the Office of Workers' Compensation for review at (225) 342-6556.** The material should be clearly identified as a denial of hospital admission and should be addressed "Attention: Medical Manager, Office of Workers' Compensation." The director will immediately review the case and will notify the carrier/self-insured employer, admitting physician, and hospital by telephone of his agreement or disagreement with the denial decision. Follow-up notification will be sent to the claimant, carrier/self-insured employer, hospital, and admitting physician by certified mail return receipt requested. Any party who disagrees with the director's resolution may file a Disputed Claim for Compensation Form (LDOL-WC-1008), available from the Office of Workers' Compensation Administration as otherwise provided by law. 8. Review nurses should coordinate related managed care activities with the pre-admission certification request. For example, compliance with a second surgical opinion component should be checked during the physician's initial call. 9. The review process is also used to identify and refer cases for discharge planning. 10. The carrier/self-insured employer will provide written notification of the review decision to the claimant, attending physician and the hospital. 11.a. The carrier/self-insured employer must maintain appropriate internal documentation of each request for pre-admission certification to verify the process and the decision for claims processing and reporting purposes. b. If a patient does not enter the hospital on the proposed date of admission (or within 15 days following that date) re-certification is required. In such cases the caller should contact the carrier/self-insured employer to re-affirm the previously submitted pre-certification data and have the admission re-certified. E. Pre-Admission Review Preparation 1. Preparation a. Educational Program for Providers. The carrier/self-insured employer will develop and distribute provider notices announcing the pre-admission certification program, describing the reasons for implementation and operation, including an explanation of the appeals process. This notice of the pre-admission certification program may be included in local carrier/self-insured employer provider newsletters. b. Pre-Admission Review Forms. The carrier/self-insured employer may use the samples attached (Exhibit 1 and 2) or develop forms to capture pertinent patient and provider information during the pre-admission certification activity. These forms may be identical to those used by the carrier/self-insured employer for their other business. However, they should capture the statistical data elements required by the Office of Workers' Compensation Administration. i. Exhibit 1, Pre-Certification Activity Sheet EXHIBIT 1 PRE-CERT ACTIVITY SHEET name of claimant | social security number | date of injury address of claimant | city | state | zip code sex |  male |  female | claimant's date of birth name of hospital address | city | state | zip code proposed date of admission | diagnosis and/or icda & cm | expected length of stay major procedure | plan of treatment | complications medical justification provider number | primary physician | callers name and number attending physician's name | phone number address | city | state | zip code is surgery anticipated? if yes, procedures  yes  no | is general anesthesia required?  yes  no ___________________ 75% 90% date ( ) ( ) | ___________________ days ____________________________ past 75% certificatgion no. appeal | out pt. | mmc/snf | recert | changes | n & m recerts | changes 1. no. of recert days _______________ no. of recert days to show _______________ File d c actuve _______________ date _______________ | date of service ___________________________________________________ change 2. no. of recert days _______________ no. of recert days to show _______________ File d c actuve _______________ date _______________ 3. no. of recert days _______________ no. of recert days to show _______________ File d c actuve _______________ date _______________ 4. no. of recert days _______________ no. of recert days to show _______________ File d c actuve _______________ date _______________ 5. no. of recert days _______________ no. of recert days to show _______________ File d c actuve _______________ date _______________ ii. Exhibit 2, Pre-Certification Case Notes exhibit 2 | pre-certification case notes claimant's name | claimant no. | precert no. date | claimant status | recert days c. Standardized Form Letters i. The carrier/self-insured employer will develop letters announcing results of the pre-admission certification process to: (a). claimant; (b). the admitting physician; or (c). the hospital, with appeals process information where necessary. ii. Exhibit 3, Pre-Admission Approval Letter Re: Patient: Pre-Admission Certification No.: Claimant No.: Date of Service: Hospital: The admission to the hospital referenced above has been initially approved for (number of days) days. It is important for you to know that..... this approval of the inpatient hospital setting is based on information provided by the above listed hospital and/or physician. The determination of actual benefits..... can only be made upon receipt of the completed claim. Payment for the services received is subject to statutory limitations. Eligibility is dependent upon: 1. the medical necessity for the services provided; and 2. the work-relatedness of the illness or injury. If the claimant requires continued hospitalization beyond the number of days approved..... the admitting physician or authorized hospital representative should contact the carrier/self-insured employer at (phone number) on or before the above days expire. Benefits for services rendered during additional hospital days not certified may be denied. iii. Exhibit 3-B, Pre-Admission Denial Letter Re: Patient: Pre-Certification No.: Contract No.: Date of Service: Hospital: Dear (claimant/physician/provider) The medical director for (carrier/self-insured employer) has carefully reviewed the pre-certification request for admission to the hospital referenced above. Based upon information obtained, it has been determined that the medical necessity of the admission has not been documented. As a result of the findings, this letter is to notify you that (carrier/self-insured employer) will not consider payment for the requested admission. If you disagree with this decision, you may appeal in accordance with the guidelines attached. Sincerely, 2. Implementation a. Telephone Inquiry Service. Telephone numbers should be published in educational materials and standardized form letters to the physicians, hospitals, and claimants. This telephone service allows for prompt response to requests for review and to general inquiries about the review process. b. Appropriate Staff and Documentation for Program Management of Certified, Denied and Appealed Admissions. Registered nurses and physicians are the recommended staff for processing of pre-admission certification requests and inquires. Procedures must be available for timely review of appealed or denied admissions by a physician (a psychiatrist for mental illness or substance abuse admissions). Program procedures should be routine and documented. 3. Evaluation a. Data Collection. Pre-admission certification documentation should be linked to the payment system to properly process inpatient claims. The pre-admission certification documentation should be retrievable on a claim-by-claim basis for compilation and classification of activity performance. b. Carrier/Self-Insured Employer Data Reporting. Carrier/self-insured employer will be required to collect the following data according to the Office of Workers' Compensation Administration requirements. Information | Positions | Type ICD-10-CM | 5/7 | Numeric Provider Name | 30 | Alpha Provider Street Address | 30 | Alpha Numeric Parish Code for Provider of Service (Use Standard FIPS code, see Exhibit 5) | 3 | Numeric Place of Treatment | 1 | Alpha Numeric Type of Facility* | 6 | Numeric Type of Service: Medical vs. Surgical | 1 | Alpha Numeric Claimant Name | 30 | Alpha Claimant Social Security Number | 9 | Numeric Length of Stay | 4 | Numeric *See "Type Facility Codes" in Exhibit 6. c. Exhibit 5 F.I.P.S. Area Codes 001 Acadia | 045 Iberia | 089 St. Charles 003 Allen | 047 Iberville | 091 St. Helena 005 Ascension | 049 Jackson | 093 St. James 007 Assumption | 051 Jefferson | 095 St. John the Baptist 009 Avoyelles | 053 Jefferson Davis | 097 St. Landry 011 Beauregard | 055 Lafayette | 099 St. Martin 013 Bienville | 057 Lafourche | 101 St. Mary 015 Bossier | 059 La Salle | 103 St. Tammany 017 Caddo | 061 Lincoln | 105 Tangipahoa 019 Calcasieu | 063 Livingston | 107 Tensas 021 Caldwell | 065 Madison | 109 Terrebonne 023 Cameron | 067 Morehouse | 111 Union 025 Catahoula | 069 Natchitoches | 113 Vermillion 027 Claiborne | 071 Orleans | 115 Vernon 029 Concordia | 073 Ouachita | 117 Washington 031 DeSoto | 075 Plaquemines | 119 Webster 033 East Baton Rouge | 077 Pointe Coupee | 121 West Baton Rouge 035 East Carroll | 079 Rapides | 123 West Carroll 037 East Feliciana | 081 Red River | 125 West Feliciana 039 Evangeline | 083 Richland | 127 Winn 041 Franklin | 085 Sabine 043 Grant | 087 St. Bernard | 998 Out-of-State d. Exhibit 6a Type Of Facility Code General Type Provider (Position 1 and 2) 00 | Not Licensed | 36 | Alcohol/Drug Rehab Center (CDU) 01 | Hospital* | 37 | Special Care Unit-Behavior Modification 02 | Skilled Nursing Facility* | 38 | Outpatient Surgical Unit (Hospital Based) 03 | Custodial Nursing/Rehab Facility | 39 | Hospice 04 | Physician (M.D.) | 40 | Licensed Massage Therapist (MA) 05 | Home Health Agency* | 41 | Doctor of Education (EdD) 06 | Dentist (D.M.D.-D.D.S.) | 42 | Lithotripter Facility 07 | Pharmacy (not hospital) | 43 | Master of Science (M.S.) 10 | Ambulance (non-hospital) | 44 | Certified Substance Abuse Counselor (CSAC) 11 | Podiatrist (D.P.M.) | 45 | Counseling and Biofeedback Therapy 12 | Psychologist (Ph.D.) | 46 | Family Counseling, Pastoral Counseling 13 | Chiropractor | 47 | Oriental Medical Doctor (O.M.D.) 14 | Osteopath (D.O.) | 48 | Certified Surgical Technician (C.S.T.) 15 | Registered Nurse (R.N.) | 49 | Doctor of Divinity (D.D.) 16 | Surgical Center (free standing) | 50 | Private Duty Nursing 17 | Radiation Center (free standing) | 51 | Multiple Specialties 18 | Renal Dialysis Center (free standing) | 52 | Radiology (Non-Hospital) 19 | Certified Registered Nurse Anesthetist (CRNA) | 53 | VA/Military Hospital/ Acute Care 20 | Physical Therapist | 54 | VA/Military Hospital/ Psychiatric 21 | Optometrist | 55 | VA/Military Hospital/CDU 22 | Registered Sitter | 56 | VA/Military Hospital/SNF 23 | Optical Dispensary | 57 | VA/Military Hospital/HHA 24 | Medical/Surgical Supply Organization | 58 | VA/Military Hospital/ Ambulatory Surgery 25 | Other Para-Medical | 59 | Registered Dietitian (R.D.) 26 | Hearing Aid Dealers | 60 | Cardiac Catherization Facility 27 | Audiologist | 61 | Residential Treatment Center 28 | Speech Pathologist | 62 | Eating Disorder Treatment Facilities 28 | Social Worker | 63 | Physician's Assistant 30 | Licensed Practical Nurse | 64 | Third Party Liability 31 | Public Conveyance | 65 | Emergency Room Physicians 32 | Rehabilitation Center | 66 | Medical Staff Services 33 | Pre-admit Testing Facility | 67 | Mental Health Clinic 34 | Alcohol/Drug Rehabilitation Center (CDU) Detox Services Only | 68 | Sperm Banks 35 | Psychiatric Hospitals-Inpatient and Outpatient | 69 | Home Infusion Therapy *If position 1 and 2 are 01, 02, or 05, use the additional codes on the next page, otherwise, the remaining four positions of the Type Facility Code may be filled with zeros (0's). e. Exhibit 6b Type of Facility Code Specific Type Provider (Position 3 and 4) If General Type (Position 1 and 2) is 01: 01 | General Short Term | 03 | Official Health Agency 02 | General Long Term | 04 | Rehab. Facility Based Program 03 | TB | 05 | Hospital Based Program 04 | Psychiatric | 06 | S.N.F. Based Program 05 | Chronic Disease | 07 | Proprietary 06 | Specialty Short Term | 08 | Other 07 | Specialty Long Term | Ownership/Management (Position 5 and 6) 08 | Christian Science | If General Type (Position 1 and 2) is 01 or 02 or 05: 09 | All Others | 01 | Church If General Type (Position 1 and 2) is 02: | 02 | Other Than Church 01 | Skilled Nursing Facility | 03 | Proprietary 02 | E.C. Unit of Hospital | 04 | State 03 | E.C. Unit of Rehabilitation Center | 05 | Parish (County) 04 | E.C. Unit of Domiciliary Institution | 06 | City 05 | Distinct part of S.N.F. | 07 | City-Parish (County) 06 | Christian Science | 08 | Hospital District 07 | Combined with Intermediate Care | 09 | P.H.S. (Fed. Gov't.) 08 | Intermediate Care Facility Only | 10 | Other than P.H.S. (Fed Gov't.) 09 | Other | 11 | All Other If General Type (Position 1 and 2) is 05: | 12 | Nonprofit 01 | Visiting Nurse Association 02 | Combined Govt. and Vol. Agency