Policies,Administrative,UW Health Administrative,Fiscal Affairs

Insurance or Managed Care Prior Authorizations and Notifications (2.21)

Insurance or Managed Care Prior Authorizations and Notifications (2.21) - Policies, Administrative, UW Health Administrative, Fiscal Affairs


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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: Insurance or Managed Care Prior Authorizations and Notifications
Policy Number: 2.21
Effective Date: June 1, 2016
Chapter: Fiscal Affairs
Version: Revision

To assure appropriateness of hospital admissions and outpatient procedures and compliance with prior
authorization/pre-admission requirements imposed by managed care insurance plans, commercial
insurers, and Metastar (for Medicare and Medical Assistance admissions.)


InterQual criteria and other relevant resources, will be used as a guide to determine the appropriate patient
status (refer to Administrative Policy 1.03-Patient Status and Observation Patient Management for
details). All non-emergent admissions and outpatient procedures (regardless of payor source) will be
reviewed by Admissions to assure the appropriateness of hospitalization and level of care, as well as
compliance with payor-based admission authorization requirements. The appropriate payor will be
contacted prior to patients' admissions. In the case of an emergent admission; the ED Case Manager will
review for appropriate patient status. Any required payor notification will be provided by Admissions.

A. Scheduled Preadmissions (Inpatient and Outpatient)
1. The physician responsible for the admission (or designee) will submit a request via
Health Link for a surgical case or medical pre-admission reservation. The pre-admission
is a prerequisite for an admission, surgery or GI procedure. The information provided is
utilized in obtaining authorization from insurance companies for treatment or admission
of the patients. Complete and timely submission of this information is critical as most
payors have strict timetables regarding pre-admission notification time frames.
2. Admissions will screen the pre-admission information received and initiate the insurance
verification process. All scheduled pre-admissions will be screened for appropriate
patient class (level of care) by the Admissions Pre-certification nurses. Screening will be
based on InterQual criteria.
3. The patient's insurance coverage will be verified and if required, prior authorization will
be obtained by the Prior authorization staff. The staff will review the medical record,
relevant clinic notes, labs, x-rays, special procedures, etc. with the Insurance Case
Managers associated with the patient's insurance company.
a. When the prior authorization has been obtained, the approval and number of days
authorized is documented in Health Link. Requests for concurrent review are

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entered into Health Link and relayed via an electronic work queue to UWHC
Case Management for follow up during the patient's hospital stay.
b. If the prior authorization is denied, the Prior Authorization staff notify the
admitting physician. If the admitting physician concurs, the admission is
cancelled or the patient class may be changed. The patient is notified of any
cancellation by the Admissions staff or the physician's office.
c. Requests from insurance companies/review organizations for additional medical
information beyond that provided by UWHC Case Management (during the
concurrent review process) are referred to the attending physician. UWHC Case
Managers inform the attending physician of the request and impending phone
call. The Case Manager then follows up with the insurance company/review
organization regarding the outcome of this discussion.
d. Denials received after a patient's discharge will be handled retrospectively by
Denial Management staff in the Revenue Cycle.
B. Unscheduled Admissions
1. Unscheduled patients may be admitted directly from clinics, the Emergency Department
or are transferred from outside healthcare facilities.
2. A bedside interview is done by Admissions after the patient is placed on a nursing unit.
Admissions will verify insurance eligibility and benefits and provide admission
notification to insurance companies within 24-48 hours of admission or the next business
3. Requests from insurance companies/review organizations for additional medical
information beyond the initial notification information will be provided by UWHC Case
Management during the concurrent review process.

Sr. Management Sponsor: VP, Revenue Cycle
Author: Director, Access Services; Director, UW Health Home Care & Coordinated Care

Approval Committee: UW Health Administrative Policy and Procedure Committee


Ronald Sliwinski
President, University of Wisconsin Hospitals
Chief of Clinical Operations

Revision Detail:

Previous revision: 062013
Next revision: 062019