Notifications and admissions

Evry Health requires inpatient notification for all hospital stays. If the service has already been prior authorized, the prior authorization will serve as notification. You do not have to submit a separate notification for those same services.

All unplanned hospital stays require length of stay review for medical necessity within 3 business days of hospital admission. Out-of-network facilities are required to request authorization after emergency screening and stabilization of services within 3 business days. For instructions on submission see “How to submit notification of admission and extension of services request”.

Members with health plan benefits which exclude out-of-network coverage will not be responsible for facility charges where the facility failed to request timely authorization for inpatient and length of stay review after emergency room services. Notification is the responsibility of the facility providing the service.

The following services require notification for admission within 3 business days and notification of discharge within 24 hours:

• Unplanned admissions: ALL medical, maternity, and surgical inpatient admissions
• Observation stays resulting from ER visit over 48 hours
• Observation stays, unanticipated after surgery or other procedure over 48 hours
• Maternity admission for vaginal delivery or C-section
• All out-of-network/out of area stays or admission

1. Step 1

   A notification must be submitted within 3 business days of admission. All notifications MUST be faxed to 325-603-0541 to be reviewed.

2. Step 2

   If the facility deems an inpatient admission is NOT required following emergency room services, the facility would fax a notification of discharge within 24 hours of discharge.

3. Step 3

   If the facility deems an inpatient admission is required following emergency room services and stabilization, the facility MUST request authorization for extension of services for medical necessity review and length of stay request. Complete medical records are required to begin the medical necessity review for length of stay request.

   Medical records may include:

   • Hospital demographic sheet
   • Admitting history and physical, ER notes, clinical progress notes
   • Medication list, vital signs, imaging, or other diagnostic procedure results. If the patient is transferred from another acute care hospital or is under observation in your hospital, please include:
   • Specialty consult note(s)
   • Last 3 days of attending physician and nursing notes
   • Estimated discharge date, discharge plan, and any foreseen barriers to discharge
4. Step 4

   If supplemental information is required, Evry Health will be in contact with the facility on what is required to conduct the review. Please note, failure to submit the appropriate documentation and lack of timely delivery may result in a denial of coverage.

Medical records need to be submitted to us prior to discharge and discharge notification is required. Please fax medical records to 325-603-0541.

Medical records may include:

• Hospital demographic sheet
• Admitting history and physical, transfer notes, ER notes
• Medication list, vital signs, labs, imaging, or other diagnostic procedure results

If the patient is transferred from another acute care hospital or is under observation in your hospital, please include:

• Specialty consult notes
• Last 3 days of attending physician and nursing notes
• Estimated discharge date, discharge plan, and any foreseen barriers to discharge

Concurrent review of services must be submitted to Evry Health via fax at 325-603-0541 within 3 business days of the last approved day in order for length of stay review to be conducted.

When submitting length of stay request, please include the following information:

• All physician, nursing, and specialty provider notes since the previous authorization
• Vital signs, physical assessments
• Medication list, labs, imaging, or other diagnostic testing that was performed
• Estimated discharge date, discharge plan, and any foreseen barriers to discharge
• Length of stay request/next anticipated review date

Please note, failure to submit the appropriate documentation and lack of timely delivery may result in a denial of coverage. If facility fails to meet time requirements, the member cannot be billed for these services.