Effective 5/1: Retrospective Utilization Review for Behavioral Health Inpatient Admissions

Date: 01/29/20

Update to Notice: Please review the latest article for full details.

Superior HealthPlan continually reviews policies and processes with the goal of minimizing the administrative burden placed on providers. As a result of the most recent review, Superior is modifying its procedures for medical necessity review for inpatient level-of-care behavioral health admissions, including those for mental health and inpatient detoxification for both alcohol and substance abuse.

Effective May 1, 2020, Superior is transitioning to retrospective utilization review for inpatient behavioral health admissions. With this change, notification of admission will continue to be required at the time of admission.

The transition to retrospective utilization review will eliminate the requirement for clinical staff in the facility to secure authorization for inpatient days following the date of admission, and allow professional hospital staff to focus on the care and treatment of the member/patient. In further support of the clinical staff in the facility, Superior will increase support for discharge planning for inpatient behavioral health admissions, including phone and on-site support to promote positive outcomes for the treatment of the member/patient following discharge from the facility.

To facilitate the retrospective utilization review, clinical documentation to support the medical necessity of the inpatient admission must be included with the submission of the claim for the inpatient stay. The clinical documentation will be reviewed simultaneously with the processing of the claim. In the event that Superior cannot substantiate medical necessity for one or more inpatient days through the retrospective review, providers will continue to be afforded peer-to-peer discussions, prior to denial, and medical necessity appeal on behalf of the member/patient, for any days denied due to lack of medical necessity.

Superior will provide additional specific information to all facility providers regarding claim and clinical documentation submission requirements well in advance of the transition to retrospective review. For questions regarding this change, or if your facility is interested in partnering on discharge planning for your Superior patients, please contact your assigned Superior Account Manager for further information.

Superior appreciates the quality care you provide to our members and looks forward to the continued collaboration with your facility, in the provision of inpatient behavioral health services.