Reviews & Requests for Patient Information for Payment Purposes (2.22)

Reviews & Requests for Patient Information for Payment Purposes (2.22) - Policies, Administrative, UWHC, UWHC-wide, Fiscal


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Administrative (Non-Clinical) Policy
 UWHC only (Hospital Administrative-entity wide)  UWMF only (entity wide)
 UWHC Departmental (indicate name)  UWMF Departmental (indicate name)
 UWHC and UWMF (shared)
Policy Title: Reviews & Requests for Patient Information for Payment Purposes
Policy Number: 2.22
Effective Date: November 1, 2015
Chapter: Fiscal
Version: Revision

To establish guidelines for effective and efficient communication with third party payors and care
managers external to the hospital. To ensure patient confidentiality and review of records by properly
authorized individuals and/or organizations.


A coordinated approach is required to respond to payer-initiated inquiries regarding a patient's course of
treatment to ensure appropriate reimbursement and to provide the appropriate level of care.

A. Pre-admission Review
1. Pre-admission planning information provided by the attending physician to Admissions
(when an admission is scheduled) is relayed to insurance companies/case management
reviewers/review organizations/third party administrators/HMO's/PPO's requiring a pre-
admission certification.
2. Requests for additional information are handled by the Precertification Coordinator
(Admissions), who obtains the required information via Health Link, or by contacting the
admitting or referring physician. For additional details regarding managed care pre-
authorization requirements refer to Administrative Policy 2.21-Insurance or Managed
Care Pre-authorizations and Notifications.
B. Concurrent Review for Length of Stay by UWHC Coordinated Care and Case Management
When the process is initiated by UWHC, an Insurance Verifier in Admissions verifies insurance
benefits and asks whether:
1. Concurrent review is required?
a. If the answer is No: the verification is completed in Health Link.
b. When the answer is Yes, pertinent notes regarding the requested review and
benefit eligibility are documented. UWHC Coordinated Care & Case
Management is notified of the request via Health Link work queue. UWHC
Coordinated Care & Case Management periodically updates the review
organization/insurance company.
2. If an Insurance Company contacts a physician directly regarding an in-house patient:

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a. The physician's staff should direct the caller to UWHC Coordinated Care & Case
Management Resource Center-Utilization Review phone at 262-6086.
i. Some insurance plans require physician contact for:
 Specified services (i.e. transplants, specific chemotherapy drugs
and protocols)
 Inpatient stays beyond a specified number of days
 Questions regarding the plan of care that Coordinated Care &
Case Management is unable to answer from medical record
review and staff contacts
ii. In general, when a Medical Director or physician (on behalf of an
insurance company) initiates an inquiry regarding a patient, it usually
requires a response from the UWHC attending physician.
C. On-site Reviews by HMO's and Review Organizations
1. Representatives of HMO's and utilization review organizations requesting on-site reviews
will check in with the Coordinated Care and Case Management Department in E5/620
each time they come to the hospital to review electronic charts (unless alternative
arrangements are specified contractually).
a. Representatives must present some form of identification from the organization
they represent. (This identification must indicate that the individual is authorized
by the organization to perform on-site reviews.) They will sign in with the
Coordinated Care and Case Management Department and be instructed to wear
their identification badge at all times while in the Hospital.
b. The representatives will be asked to review UWHC policies regarding
confidentiality of information the first time they present in the department. The
following Administrative hospital policies are reviewed: 2.21 – Insurance or
Managed Care Pre-Authorizations and Notifications; 2.22 - Reviews & Requests
for Patient Information for Payment Purposes; 4.13 – Using and Disclosing (or
Releasing) Protected Health Information and 4.14 - Release of Mental Health
Information. The representative will sign a statement confirming this review.
c. The Coordinated Care staff will create a Health Link report containing the
required information needed for the representative to perform the review. A kiosk
key code is provided to the representative, which provides access to perform on-
site review within Health Link for each case they review. The kiosk key code
will be valid only for that day.
d. Reviews may be conducted between 8:00AM and 4:30PM, Monday through
Friday. Exceptions to these hours must be requested through the Director of
Coordinated Care and Case Management.
2. Upon arrival on the Patient Care Unit, the reviewer must present his/her kiosk key code
to the Health Unit Coordinator or Nurse Case Manager. No reviewer will be permitted
access to any protected health information unless they have a valid kiosk key code.
3. The reviewer agrees to phone the UWHC Coordinated Care and Case Management
Department with their findings within 24 hours of their review (or the first business day
following their review). UWHC Coordinated Care staff will notify appropriate M.D.'s,
and the Case Manager.
4. It should be noted that, in instances where UWHC is the exclusive hospital of an HMO
(i.e. Unity and Group Health), their review representatives would be exempt from this
check-in procedure for on-site review. These requirements are addressed contractually.
D. HMO/Review Organization Attendance At Specific Patient/Family Care Conferences
1. Prior to their arrival at UWHC, the HMO/Review Organization must submit to UWHC
Coordinated Care & Case Management/Utilization Review Specialists, a written request

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to attend a specific patient care conference. Utilization Review specialist will forward
this information to the appropriate case manager.
2. Representatives of HMO's and review organizations will check in with the Coordinated
Care and Case Management Department as outlined in C1 above.
3. At the conference the Case Manager or, if unavailable, the Clinical Nurse Manager will
monitor the reviewer's attendance to assure he/she is present for only discussions relating
to the patient(s) under their review.
4. The Case Manager will also confirm and obtain as necessary the appropriate medical
record disclosures for release of information. Informed consent will be obtained for drug
and alcohol related diagnoses if not already in the medical record. In addition, patients
who have had HIV testing will have a consent form in their medical record, which
includes authorization for release of such information to an insurance company.
5. This procedure precludes attendance at patient discharge planning rounds, and walking
6. Questions and exceptions to this procedure should be directed to the Director of
Coordinated Care & Case Management.
E. Retrospective Review
1. If denials are received by the physician, a copy of this correspondence should be sent
to Admissions. Denials received in Patient Accounting will be electronically forwarded to
Admissions. Denial management is overseen by the Precertification Denial Coordinators
in Admissions.
a. The Precertification Denial Coordinator reviews Health Link, utilization review
information documented within the Extended Care Information Network (ECIN)
software program, and any additional information available within OnBase. The
Precertification Denial Coordinator contacts the attending physician to prepare a
response and/or an appeal to a denial.
2. Reporting of results
a. The number of potential denials, appeals and outcomes will be monitored and
results reported to the Revenue Cycle VP, and Coordinated Care & Case
b. The Director for Access Services will monitor the cases, which ultimately result
in a denial for patterns/trends.
F. Release of Medical Information/Patient Confidentiality
1. In most instances, the signature on the admission form adequately addresses the
authorization for release of information required for payment of the hospitalization.
2. Alcohol and drug related diagnoses require an additional release which is obtained upon
admission or upon identification of these diagnoses by Admissions, Coordinated Care
and Case Management or Patient Accounting prior to billing.
3. Admission Precertification nurses document on an electronic form in Health Link the
release of medical information mailed to insurance companies.
4. Any questions regarding the appropriateness of releasing information to third-party
payers may be directed to UWHC Coordinated Care & Case Management, the Director of
Health Information Management or the Director of Access Services.
G. Noncompliance
1. Reviewers who do not comply with the above procedures will be brought to the attention
of Hospital Administration.

Sr. Management Sponsor: CFO
Author: Director of Coordinated Care & Case Management; Director of Access Services

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Reviewer: Compliance and Privacy Officer

Approval Committee: Administrative Policy and Procedure Committee


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

Revision Detail:

Previous revision: November 2012
Next revision: November 2018