a) When a review request is submitted, what are the possible determinations?
A review performed by a URC may result in one of the following outcomes:

•  Certification - InterQual® medical necessity criteria are applied. If criteria are satisfied, the utilization review coordinator renders a medical necessity certification determination for the admission or continued stay. The certifiable length of stay is determined based on the hospital's or physician's reported estimated length of stay in comparison to Thomson Healthcare, Inc.’s (formerly Solucient, LLC) Length of Stay Norms,  which are referenced as a guideline.

• Pend for additional information - Additional clinical information may be needed to complete a review. During this time, the review is pended. When the information is received within one business day, it is removed from pend status and the review is completed.

• Suspend - When a review is pended and the requested additional information is not received within one business day, the review is suspended.

• Physician reviewer referral - When criteria are not satisfied, or the number of days requested exceeds what the nurse may certify, the utilization review coordinator will send the request to a physician peer reviewer.

 b) What are the possible determinations when a review request is sent to a physician peer reviewer?

• Certification - The physician uses the available information and clinical judgment to render a certification determination. If further information is needed, peer to peer discussion is initiated between the physician reviewer and the attending physician.

• Adverse Determination – This is a general term for an unfavorable utilization or quality finding.  Specific types of adverse determination include medically necessity non-certifications or denials, confirmed quality of care issues, and DRG change. 

c) What is an expedited reconsideration?
An expedited reconsideration is an opportunity for a hospital to appeal any adverse review finding while a patient is still hospitalized. The hospital may fax the request for expedited reconsideration and overnight the medical record to HSI.

d) What is a standard reconsideration?
A standard reconsideration is an opportunity for a hospital to appeal any adverse review findings that may be requested after a patient has been discharged. The request must be submitted in writing and a copy of the medical record sent to HSI within 60 days of the non-certification (denial) notification.

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a) Is any consideration being offered to assist facilities faced with challenging discharges?
HSI only performs utilization review to determine the necessity of admission and continued stay, and only medically necessary days are certified.  HSI does not perform discharge planning or case management services.

b) Would “no available nursing home bed” that is documented in the discharge planning by social services validate a continued stay, i.e., non-avoidable day?
The continued stay must be medically necessary. Regarding days that the patient needs to remain in the hospital due to nursing home placement, these days may qualify for reimbursement under Skilled Care Hospital Residing (category of service 37) or DD/MI Non-Acute Care Hospital Residing (category of service 39). Refer to the HFS Hospital Handbook, Chapter 200 regarding participation requirement and enrollment procedures.

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a) Does a concurrent review need to be completed for a DRG reimbursed hospitalization?
Yes.  Even though DRG reimbursed hospitalizations are no longer subject to a length of stay review, a concurrent review is still required for HSI to conduct the quality of care screening at the time of the patient’s discharge.  

b) Will I still receive a daily list if my cases are DRG reimbursed?
Yes.  The daily list will show DRG reimbursed admissions with a “D” marked next to it.  The “D” marked admissions need to have a concurrent review request submitted upon the patient’s discharge.  An asterisk will appear next to a case with an entered discharge date.  This indicates that a concurrent review for quality of care screening is still needed. This will stay on the daily list for 90-days or until the concurrent review is complete.    

c) When can I submit a concurrent review for a DRG reimbursed hospitalization?
The concurrent review should be submitted when you can provide information about the last 48 hours of inpatient care, the patient’s anticipated discharge date and discharge disposition (e.g. home with outpatient follow-up, nursing home, etc.)

d) What is required for a quality of care screening?
Every patient situation is different. Examples of information that may be requested are vital signs prior to discharge, the most recent laboratory or other test results (as pertinent to the reason for hospitalization), precautions appropriate to the clinical setting, the patient’s clinical status during the 24 hours  prior to discharge (when the patient has been admitted for more than 48 hours).

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11) Eligibility

a) If a patient has Medicare Part A as primary coverage, but all Medicare days have been exhausted, and therefore Medicaid becomes primary, is concurrent review required?
Yes, if the admitting diagnosis is on HFS’ Attachments A, B, or C.  At the time of the review request, the hospital must inform HSI that the patient has exhausted all Medicare Part A benefits.   If HSI's review nurse says that review cannot be performed, please ask to speak to a review team leader or supervisor.

b) If the patient has Medicare Part B only and the admitting diagnosis is subject to review, is a concurrent review required?
Yes

c) Is a concurrent review request required for patients with a pending application under one of HFS’ medical assistance programs?
No.

d) If the patient’s eligibility is determined after discharge and the admitting diagnosis is subject to review, should hospital staff submit a review request?
No.  However, HFS will allow limited exceptions to mandatory concurrent review.  If the participant’s eligibility was backdated to cover the hospitalization, the hospital may submit the claim to the assigned HFS Billing Consultant with a cover memorandum that explains the exceptional situation. After HFS reviews the exception request, HFS will pend the claim for retrospective prepayment review. The HSI liaison will be notified of records selected for retrospective prepayment review.

e) How can hospitals obtain information about HFS medical assistance programs eligibility after hours, on weekends, and/or holidays?
HFS has established the Automated Voice Response System (AVRS) for client eligibility inquiries. The toll-free telephone number (800) 842-1461 is available 23 1/2 hours a day to allow providers to access client eligibility information through the use of any telephone. To utilize the AVRS, the provider must have the participant’s recipient identification number (RIN). Eligibility information consists of whether the participant is eligible for one of HFS' programs, and in which program the participant is eligible specific to the date of service in question. Public Act 88-554 mandated HFS create a statewide electronic Recipient Eligibility Verification (REV) system. The REV system is available to enrolled providers throughout the state. The REV system utilizes various clearinghouses, known as REV vendors that have direct telecommunication line access into HFS’s databases. Additional information on REV system and vendors is available at http://www.hfs.illinois.gov/rev/

HFS also has another site called Medical Electronic Data Interchange (MEDI) which allows the provider the opportunity to verify a participant’s eligibility for medical assistance, submit claims or check claims status directly to HFS through the provider’s Internet browser software.  No additional hardware or special software is needed.  The provider may register to use the MEDI system by accessing http://www.myhfs.illinois.gov/

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a) Who is my HSI liaison?
The hospital’s liaison is the individual designated by the hospital's administrator to receive all review-related correspondence from HSI. This individual should distribute this correspondence to other individuals as appropriate within the facility.

b) Can the hospital change the designated HSI hospital liaison?
Yes. Updates or changes in hospital contact information must be requested in writing and signed by a CEO or CFO and forwarded to HSI. Click here to download a hospital contact form.

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a) What resources does HSI offer hospitals?
Several resources are offered including the following:

• Provider Updates – these information notices and updates are distributed by fax to the HSI liaison and posted to the HSI Web site.

• Coding Aids - Lists containing reviewable codes from HFS' Attachment A, B and C are conveniently sorted numerically and alphabetically. These may be downloaded from the HSI Web site.

• Provider Specific Reports - Hospitals may access these through the "Reports and Communications" link on the HSI Web site.

• Provider Helpline - The helpline is available Monday – Friday from 8 a.m. to 5 p.m. through a toll-free number (800) 418-4045.

• Provider Education - Web-based review system training are currently being offered.

b) How can hospitals find out when the next Web training sessions will be offered?
Hospitals may access the Provider Education Registration page on the HSI Web site or by clicking here.

c) What are HSI’s hours of operation?
The toll-free certification lines are available Monday through Friday from 7 a.m. to  5 p.m.  Normal business hours are Monday through Friday from 8 a.m. to 5 p.m.  HSI is closed for designated Federal and State holidays. Holiday schedule is listed on HSI’s Web site or by clicking here.  Review requests may also be submitted online 24 hours a day, 365 days a year. Requests received outside of regular business hours will be processed on the business day.

d) Does HSI accept reviews requests by fax?
No. HSI accepts requests online through our Web-based review system 24 hours a day, 365 days a year, or by calling the toll-free certification line at (800) 418-4033, Monday through Friday from 7 a.m. to 5 p.m., except for designated Federal and State holidays. Requests received outside of regular business hours will be processed the following business day.

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a) What do hospitals do if the physician does not have a HFS provider number?
If the physician does not have a HFS provider number, please call HSI's toll-free certification line at (800) 418-4033 to submit the admission review request. HSI will create a temporary ID for the physician. Hospitals may then submit any continued stay reviews either by web or by phone.

b) How are physician peer reviewers matched to the case they are reviewing?
Physician peer reviewers are matched by specialty and/or service provided.

c) Are attending physicians given an opportunity to interact by phone with physician peer reviewers and supply additional information?
Yes. The physician reviewer will make two attempts to contact the attending physician to discuss the review before any adverse determination (medical necessity non-certification, confirmed quality of care issue, or DRG change) is made.  The hospital or attending physician may request a reconsideration of an adverse determination.

d) For physician review of child psychiatric cases, will there be a child psychiatrist available to review the cases?
Child psychiatrists are among HSI's physician peer reviewers. Every effort will be made to match the physician peer reviewer's experience with that of the patient’s attending physician.

e) Is there a penalty to physicians for non-medically necessary hospitalizations?
No. The physician's claim and the hospital's claim are not linked. We will notify the attending physician when a review results in an adverse determination such as a medical necessity non-certification (denial).

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a) Who performs admission certifications for psychiatric admissions to an inpatient unit?
The reviews are performed by HSI utilization review coordinators who are registered nurses applying InterQual® Behavioral Health Criteria, a nationally-recognized screening criteria. All nurse reviewers are trained to apply behavioral health review criteria, and some have several years of inpatient psychiatric nursing experience. In addition, our physician reviewers, board certified in psychiatry, are available to provide ongoing training and consultation when necessary.

b) How are pass days handled with the concurrent review requirement?
Since the patient is not receiving in-patient acute care during pass days, they should be recorded as non-covered days. Only days that are medically necessary will be certified. The non-covered days need to be reflected on the UB-92/UB-04 or 837I (electronic transaction). The covered days on the claim must be equal to or less than the length of stay certified or the claim will be rejected.

c) What is the procedure when a patient is admitted for a medical condition that does not require admission review, but during the stay, the patient’s primary diagnosis changes to a psychiatric diagnosis?
The hospital must discharge the patient from the medical service and admit the patient to the psychiatric service, using the appropriate admitting diagnosis. When this occurs, it changes the category of service for the inpatient stay. The hospital must submit separate claims if there is a change in the category of service. If the admitting diagnosis is subject to concurrent review for the inpatient stay, a certification of admission must be requested. In this case, the clinical information for the psychiatric condition will need to be provided to us within one business day of the admission for acute inpatient psychiatric care.

d) If a patient requiring a psychiatric admission presents to the ER, is the ER staff required to call for pre-certification before transferring the patient to the psychiatric unit?
No. HSI does not perform prior-authorization or pre-certification review. Hospital staff or physicians should submit admission review request within 24 hours of the patient’s admission or as soon thereafter as possible.  

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a) When a hospitalization is reviewed through the admission/concurrent review process, is it reviewed for quality?
Behavioral health hospitalizations and medical/surgical hospitalizations are subject to a concurrent quality screening process. The concurrent quality screening is performed to identify potential quality of care issues. Should a potential quality of care issue be identified in the concurrent review, it will only be confirmed after a full chart review by a physician peer reviewer.

b) What is the difference between quality of care screening and quality review?
The quality of care screening is conducted during the admission/concurrent review process.  It is based on the information provided by the facility via phone or web submission. A comprehensive quality review is conducted during a retrospective review only.  Please see Definitions for more complete explanation.  

c) Who determines if a quality issue exists?
Only a physician peer reviewer can determine if a quality of care issue exists and only after review of the entire medical record. Validation of a serious quality of care issue and quality of care pattern are determined only after review by a physician peer review panel. The physician peer review panel consisting of at least three physician of the same specialty of the cited physician/care.

d) If we receive notification of a potential quality issue, are we required to respond?
When a potential serious quality of care issue is identified, the cited party is offered an opportunity to submit additional information about the concern or discussed with a physician peer reviewer. Though a response is not required, it is in the interest of the cited party to provide any information that might be relevant to the quality concern before a final determination is rendered.

e) Are quality determinations reported to any outside entity?
The quality of care determinations are reported to the Bureau of Medical Integrity (BMI) and to HFS in writing of the validated quality issue.  The cited party(ies) are notified of the final determination with a request of Quality Improvement Plan (QIP).

f) What is a QIP and is it requested whenever a quality issue is identified?
A QIP is a Quality Improvement Plan. A QIP is requested when a serious quality issue (s) are validated by a physician peer review panel. A QIP can also be requested if a pattern of quality issues are identified.

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a) What notification will I receive once a determination has been made?
Notifications depend on the review outcome and, for some reviews, the method by which the review was performed.

Certification (approval) of medical necessity for review requests made by phone: The hospital will receive immediate verbal notification of certification. Also, a written notification will be sent to the hospital HSI liaison. Hospitals set-up with auto fax will receive a fax notification. All others will be mailed. The hospital may also check the review status and determination online through HSI's provider specific Web reports.

Certification (approval) of medical necessity for reviews requests submitted online: A written notification will be sent to the hospital HSI liaison. Hospitals set-up with auto fax will receive a fax notification. All others will be mailed. You may also check the review status and determination online.

Non-certification (denial) of medical necessity: Before rendering a medical necessity non-certification determination, two attempts are made by the physician reviewer to contact the attending physician by phone. During the phone conversation, our physician reviewer informs the attending physician of the determination. HSI also provides phone notification to the hospital representative who submitted the review request. However, please note that if HSI calls to advise the hospital representative of the non-certification and is routed to an answering machine or voicemail, a message containing any patient information cannot be left unless the voicemail greeting specifically states that it is a confidential or secured voicemail box or answering machine. Written notifications are mailed to both the hospital's HSI liaison and the attending physician. Notifications include an explanation of the reconsideration process. Hospitals may also check the review status and determination online.

b) Will the hospital be notified if they need to submit a concurrent/continued stay review request?
HSI faxes to the hospital’s HSI liaison a daily list of all in-process reviews. These in-process reviews have had an admission review completed. The daily list will show a “D” marked for DRG reimbursed hospitalizations and a “P” marked for Per diem hospitalizations. Depending on the type of hospitalization, the case will need either a continued stay review or a discharge review submitted. The hospital may submit a continued stay review request if additional days need to be certified or a concurrent review for DRG reimbursed hospitalizations for the quality of care screening.

c) What reports are available to a hospital?
A variety of provider specific reports are available online through the "Reports and Communications" link on the HSI Web site. To access these reports, the hospital's HSI Web administrator must assign a user name and password and give access to the reports area.

d) Will HSI’s certification notifications include the date that it was sent?
Yes. The written Notice of Review Approval or Notice of Denial is dated. The date of submission of the hospital’s or physician’s request for certification is also included.

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a) What is the procedure for sending in medical records to be reviewed retrospectively?
The hospital HSI liaison will receive a Notice of Selection of Medical Records for Offsite Review. The hospital copies and mails the charts to HSI within 14 days from the date on the letter. The hospital will be reimbursed copying charges on a quarterly basis at the rate of $0.10 for each page or $0.20 for double-sided pages.

b) What is reviewed during retrospective review?
The medical necessity of the admission, each day of care and the appropriateness of invasive procedures are reviewed. In addition to the medical necessity and appropriateness reviews, HSI conducts quality of care review, validates the accuracy of billed ICD-9-CM and DRG codes, and reviews for critical billing errors.

c) Will an HSI utilization review nurse be coming to the hospital to perform retrospective reviews?
In an Informational Notice dated November 28, 2006, HFS notified hospitals that effective March 1, 2007, HSI will conduct only off-site reviews for all diagnosis codes and DRGs subject to review. Hospitals are required to submit the medical record to HSI’s office. Additionally, the hospital will be required to submit the medical record for inpatient stays selected for post-payment review. HSI will continue to provide the hospital HSI liaison with the list of records to be reviewed. Please click here for important information for submitting medical records to HSI for review.

d) Once a continued stay review is certified, will the same case ever be selected for retrospective post-payment review?
It may be. The case may be selected as part of a retrospective post-payment review sample to review for quality of care, to validate the information provided during concurrent review, and to review for coding accuracy.

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a) When entering a Web review, how can I move to the next field?
After entering in the data field, press the TAB key to advance to the next field.  Pressing enter will not work.

b) Is there a way to copy and paste information from other electronic files into your Web review system?
Yes, HSI Web-based system is Microsoft® Windows-based so hospitals may use the convenient copy and paste feature.  However, it is important to note that the clinical information pasted into the review screens should be pertinent and specific to the review request. Do not paste the entire electronic chart. Please review the information and delete any extraneous data.

c) What if there is not enough space when to type in the patient’s information in the clinical screen?
Our system allows for up to 1,500 character spaces in the clinical screen. Per the Web User Guide, type across the entire line in the clinical screens and let the automatic word wrap take it the next line. It is important to delete empty spaces on each line to condense the information when copying and pasting.  If more than 10 lines of clinical information are typed, a scroll bar will appear on the right side of the screen to allow for extra space. Continue to type the information or copy and paste it into the field. It is important to only include in the clinical information that is pertinent and necessary for the review.

d) What if the admitting diagnosis code (Admit DX) is invalid or not subject to review?
If a message pops up that the admitting diagnosis code is an invalid code, please double check that the code is subject to review.  Also check to make sure there is not a typo or any periods in this field.  HSI posts Coding Job Aids on our Web site, which are lists of the ICD-9-CM admitting diagnosis codes subject to review.  Please cancel out of the review.

e) What if my User Identification (ID) and Password are invalid?
User IDs and passwords are case sensitive, use lowercase when typing.  If this does not work, please contact the designated HSI Web Administrator.  The Web administrator has the ability to look up and verify User IDs and passwords, and check user’s access to submitting Web review requests.  Some users have limited access.

f) Is there a way to print out Web review request to keep in the patient’s medical record?
Yes, after submitting the review request, exit out of the system.  Click on the “Reports and Communications” link on www.hsofi.org and choose Report #5, Printout of Web Entered Review Request. (the tracking number is needed from the original request)

g) Is there a field to add in the attending physician’s correct phone or pager number?
No, there is no specific field for this information.  However, we encourage each requestor to enter the attending physician’s contact information in the Treatment Plan Screen, after the pertinent information is entered.   

h) What if the HSI Web Administrator is unavailable or unable to answer questions?
Hospital’s should call our toll-free provider helpline at (800) 418-4045 and explain the issue. The helpline coordinator will be able to answer general questions. The provider helpline is available Monday through Friday from 8 a.m. to 5 p.m., C.T.

i) What if an error message pops up reading “This is a Children’s Mental Health Admission and there is no corresponding entry on file from CARES/SASS”?
The recipient/diagnosis combination requires that the individual in questions be enrolled in the Screening, Assessment and Support Services (SASS) program.  Hospitals are required to contact the Crisis and Referral Entry Services (CARES) prior to admission for individuals requiring SASS involvement.  Upon contacting CARES, the hospital should indicate that they need an HSI entry number – CARES will create an entry number and provide it to the hospital.  This Hsi entry number will allow you to proceed with your Web entry.  The CARES line can be reached at (800) 354-9049.

j) What type of information is required for certain fields in the Web-based review system (example what is TPL)?
Each field contains a guide as to what information is needed.  Click in the field and press the F1 key on the keyboard.  The F1 function key will bring up a text box with information regarding that field. Also, the HSI Web User Guide is a great reference which can be downloaded at www.hsofi.org

k)  Is the information secure and protects confidentiality when submitting a review request via the Web-based review system?
Information submitted as part of the online review request process is encrypted to ensure confidentiality.

l) How can hospitals find out when the next Web training sessions will be offered?
Hospitals may access the Provider Education Registration page on the HSI Web site or by clicking here.

m) What should a hospital do when entering in a Web review request and an error message pops up stating “covered under Medicare Part A - no review needed” but the hospital knows that Medicare Part A coverage has been exhausted for the patient?
The hospital must first “cancel” out of the review request and then call HSI’s certification line at (800) 418-4033 to request the review by phone.  Please inform HSI's review nurse that Medicare Part A is exhausted.  If HSI's review nurse says that review cannot be performed, please ask to speak to a review team leader or supervisor.