It’s important for Point32Health’s utilization management (UM) team to collaborate with you on care and discharge planning to monitor the patient’s progress, help ensure that they receive the right care based on their health needs, and assist in a smooth transition of care.
To that end, we’re sharing a reminder regarding continued stay reviews for diagnosis-related group (DRG) case rate admissions for Harvard Pilgrim Health Care Commercial, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether members, as well as an update to our level of care review process for elective inpatient surgical procedures effective for dates of service beginning Feb. 27, 2025 for Harvard Pilgrim Commercial members.
Continued stay reviews
As a reminder, our UM team conducts concurrent review for members admitted to an acute inpatient facility for medical and surgical care. This includes initial reviews, as well as ongoing continued stay reviews throughout the hospital admission. InterQual criteria are applied as the basis for these reviews, but these criteria do not replace Medicare or MassHealth/Medicaid coverage guidelines, which are used in making coverage determinations where available.
Providers should be aware that we will be expanding these reviews for diagnosis-related group (DRG) admissions (also known as case rate admissions) in the coming year. As a result, you may notice Point32Health reaching out to your facility more often throughout a patient’s stay for subsequent reviews of clinical information to make coverage determinations and substantiate a continued stay.
Elective inpatient level of care reviews
In addition, for Harvard Pilgrim Commercial members, as of Feb. 27, 2025 we will be applying level of care reviews to elective inpatient surgical procedures. In addition to our current review process for determining the medical necessity of a procedure, we’ll use InterQual criteria to perform level of care reviews to assess whether it’s more appropriate for the procedure to occur in the inpatient setting or an outpatient setting, such as a surgical daycare center.
The level of care review process will apply regardless of whether the procedure itself requires prior authorization.
The level of care review process for elective inpatient surgical procedures will apply only for Harvard Pilgrim internally managed cases — those managed through arrangements with our vendor partners (e.g., Evolent, formerly known as National Imaging Associates) are not included.
For additional information on utilization management and review, please refer to the applicable Provider Manuals.