NOTICE: In-Patient Behavioral Health Admission Records

Date: 10/29/20

Update to Notice originally posted 09/10/2020.

Superior HealthPlan continually reviews policies and processes with the goal of ensuring the highest quality care for our members while accounting for the needs of our providers. Superior is modifying its requirements for receipt of clinical information related to all behavioral health admissions, including concurrent and retrospective utilization review. This revision in requirements is being implemented to align physical and behavioral health concurrent utilization review for inpatient admissions, and in consideration of provider input.

Effective November 1, 2020, Superior will no longer receive clinical information telephonically for inpatient reviews. This policy is applicable for all inpatient level-of-care behavioral health admissions, including mental health, and inpatient alcohol and substance use disorders detoxification.

How to submit clinical information:

Medical record documentation for inpatient behavioral health concurrent and retrospective review can be submitted through any of the following methods:

• Facsimile - Please refer to the recent provider communication related to notification of new Superior Fax numbers, to be utilized for submission of required medical/clinical records documentation for inpatient admissions.
• Superior’s Secure Provider Portal
• Electronic Medical Records (EMR) system

What clinical information to submit:

Facilities must submit:

• All relevant and updated information and medical records related to the inpatient admission, necessary to complete the review [28 TAC §19.1707(b)], including:
  • An enrollee/member's mental health medical record summary; or
  • Medical records or process or progress notes that relate to treatment of conditions or disorders other than a mental or emotional condition or disorder [28 TAC §19.1707(d)(1-2)].

As specified in the Texas Utilization Review Rule, 28 TAC §19.1707(b)(1), the medical record documentation may include clinical and diagnostic testing information regarding the diagnoses of the enrollee and the medical history of the enrollee relevant to the diagnoses; the enrollee's prognosis; and the plan of treatment prescribed by the provider of record, along with the provider of record's justification for the plan of treatment. The required information should be obtained from the appropriate source. The documentation should also include identifying information about the enrollee; the benefit plan or claim, the treating physician, doctor, or other health care provider; and the facility rendering care.

As is currently the case, providers are afforded peer-to-peer discussion prior to denial of a concurrent or retrospective review for an inpatient stay, if the medical necessity of one or more inpatient days cannot be substantiated based on the clinical documentation received.

Superior appreciates the provider participation in our facility network, and values the continued collaboration with your facility. Please contact your assigned Superior Account Manager with any questions, or to obtain further information.