La. Admin. Code tit. 40 § I-2705

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2705 - Pre-Admission Certification

A. Pre-admission certification is the review and assessment of the medical necessity and appropriateness of non-emergency hospital admissions before hospitalization has occurred. The appropriateness of the site and the level of care is assessed along with the timing of the proposed admission. Actual payment for services is also contingent upon the carrier/self-insured employer's verification of:

1. claimant's entitlement to benefits at the time hospitalization actually occurs; and

2. statutory coverage for the care that is actually provided.

B. Application for pre-admission certification should be made prior to admission to the hospital unless the admission to the hospital is for a compensable illness or bodily injury that occurs without warning and requires immediate inpatient treatment to prevent death, disability or serious impairment of patient function. In the event an inpatient admission is for treatment of such a medical emergency, notification must be made to the carrier/self-insured employer within 48 hours of admission.

C. Louisiana Office of Workers Compensation Administration shall support both ICD-9 and ICD-10 coding formats for a period of time after the compliance date. Claims shall be accepted with ICD-9 codes for service dates or discharge dates prior to the compliance date for pre-authorized services and/or treatment or timely filing requirements. If an authorization is requested on or before the compliance date, and the date of service is on or after October 1, 2015, healthcare professionals must submit an ICD-10 code. If an authorization is requested after the compliance date, the ICD-10 code will be required. The pre-admission certification process follows the sequence below.

1. The physician, hospital, or claimant must initiate the pre-admission certification process by calling the carrier/self-insured employer. The reviewer will request the following information:

a. claimant name;

b. Social Security number;

c. date of injury;

d. claimant's address;

e. sex;

f. claimant's date of birth;

g. name of hospital;

h. hospital address;

i. anticipated admission date;

j. admitting diagnosis (to include ICD-10-CM codes);*

k. expected length of stay;

l. major procedures and related CPT/ICD-10-PCS codes;*

m. plan of treatment;

n. complications or other factors requiring the inpatient setting;

o. medical justification for inpatient admission;

p. is surgery anticipated? If yes, procedure;

q. is general anesthesia required;

r. admitting physician's name;

s. admitting physician's address;

t. admitting physician's phone number;

u. admitting physician's Tax ID or Social Security number; and

v. caller's name and number.

*The provider will provide descriptive/narrative information and the reviewer, representing the carrier/self-insured employer, will provide the ICD-10-CM, ICD-10-PCS and/or CPT-4 codes.

D. Pre-Admission Review Procedures

1. The carrier/self-insured employer must be able to administer a program where pre-admission certification review is initiated by the physician, hospital or claimant. Once the caller has made the first phone call to notify the carrier/self-insured employer of proposed hospitalization, the carrier/self-insured employer will follow through with phone calls and written confirmations to the claimant, physician and hospital.

2. Pre-admission certification review is primarily conducted by telephone during normal business hours (8 a.m. to 4:30 p.m. Central Time, Monday through Friday, excluding legal holidays) to assure quick responses. Written requests for pre-admission certification may be processed by the carrier/self-insured employer on a case by case basis.

3. The Office of Workers' Compensation Administration will require annual reports on all workers' compensation medical review activity. Automated software support for the review process is recommended in order to assure timely responses, uniform administration, and complete data gathering.

4. All non-emergency hospital admissions must be reviewed using nationally accepted criteria designed to assess the need for the acute level of care. The Appropriateness Evaluation Protocol (AEP) and the Intensity/Severity/Discharge (ISD) criteria are the two most prominent nationally accepted criteria for admissions.

a. The AEP manual is available from:

Utilization Management Assoc.

888 Worcester Street

Wellesly, MA 02811

Phone: (617) 237-6822

b. The ISD manual is available from:

Inter Qual

44 Lafayette

North Hampton, NH 03862

Phone: (603) 964-7255

5. When the medical necessity of a proposed hospitalization is approved or certified, an expected length of stay is assigned. The length of stay is based on statistical norms developed by the Professional Activities Study (PAS) of the Commission on Professional and Hospital Activities, Southern Region.

a. The PAS is available from:

CPHA Publications

1968 Green Road

Box 1809

Ann Arbor, MI 48106

Phone: (800) 521-6210

6.

a. The carrier/self-insured employer shall use registered nurses for the initial review of recommended hospitalization. Registered nurses will use written criteria provided in Paragraph D.4 above to assess proposed hospitalizations. Physicians must review all questionable cases and make the carrier/self-insured employer decisions on all denials of certifications.

b. Within five calendar days of receipt of the request, a response must be generated in writing as to whether or not the admission is approved or denied. Verbal response will be given within two working days from the time of the request followed by the written response. Copies of the written response will be sent to the attending physician, the hospital, and the claimant and must notify the parties of the right to appeal and the appeal process. Sample letters are enclosed as Clauses E.1.b.iii and iv.

7.

a. An appeals process must be available for reconsideration of any denial decisions. If the admitting physician, hospital, or claimant desires to appeal a denial of an admission or continued stay request, the appeals process is initiated by contacting the carrier/self-insured employer by telephone or other immediate means following receipt of the denial. After the appeal request is received, it will be referred to the carrier/self-insured employer medical director or physician consultant in the appropriate specialty if required. The carrier/self-insured employer medical director or physician consultant will review the available information regarding the request and make a decision concerning the appeal within 48 hours of receipt/communication of the appeal.

b. If the carrier/self-insured employer medical director decision is an approval of the appeal the admitting physician and hospital will be immediately notified via telephone and follow up by letter will be sent to the physician, claimant, and hospital.

c. If the carrier/self-insured employer medical director's decision is a denial the carrier/self-insured employer will notify the admitting physician and hospital and will immediately submit in writing the denial and case documentation by fax to the director of the Office of Workers' Compensation for review at (225) 342-6556.** The material should be clearly identified as a denial of hospital admission and should be addressed "Attention: Medical Manager, Office of Workers' Compensation." The director will immediately review the case and will notify the carrier/self-insured employer, admitting physician, and hospital by telephone of his agreement or disagreement with the denial decision. Follow-up notification will be sent to the claimant, carrier/self-insured employer, hospital, and admitting physician by certified mail return receipt requested. Any party who disagrees with the director's resolution may file a Disputed Claim for Compensation Form (LDOL-WC-1008), available from the Office of Workers' Compensation Administration as otherwise provided by law.

8. Review nurses should coordinate related managed care activities with the pre-admission certification request. For example, compliance with a second surgical opinion component should be checked during the physician's initial call.

9. The review process is also used to identify and refer cases for discharge planning.

10. The carrier/self-insured employer will provide written notification of the review decision to the claimant, attending physician and the hospital.

11.

a. The carrier/self-insured employer must maintain appropriate internal documentation of each request for pre-admission certification to verify the process and the decision for claims processing and reporting purposes.

b. If a patient does not enter the hospital on the proposed date of admission (or within 15 days following that date) re-certification is required. In such cases the caller should contact the carrier/self-insured employer to re-affirm the previously submitted pre-certification data and have the admission re-certified.

E. Pre-Admission Review Preparation

1. Preparation

a. Educational Program for Providers. The carrier/self-insured employer will develop and distribute provider notices announcing the pre-admission certification program, describing the reasons for implementation and operation, including an explanation of the appeals process. This notice of the pre-admission certification program may be included in local carrier/self-insured employer provider newsletters.

b. Pre-Admission Review Forms. The carrier/self-insured employer may use the samples attached (Exhibit 1 and 2) or develop forms to capture pertinent patient and provider information during the pre -admission certification activity. These forms may be identical to those used by the carrier/self-insured employer for their other business. However, they should capture the statistical data elements required by the Office of Workers' Compensation Administration.

i. Exhibit 1, Pre-Certification Activity Sheet

Click here to view image

ii. Exhibit 2, Pre-Certification Case Notes

Click here to view image

c. Standardized Form Letters

i. The carrier/self-insured employer will develop letters announcing results of the pre-admission certification process to:

(a). claimant;

(b). the admitting physician; or

(c). the hospital, with appeals process information where necessary.

ii. Exhibit 3, Pre-Admission Approval Letter

Re: Patient: Pre-Admission Certification No.: Claimant No.: Date of Service: Hospital: The admission to the hospital referenced above has been initially approved for (number of days) days. IT IS IMPORTANT FOR YOU TO KNOW THAT..... this approval of the inpatient hospital setting is based on information provided by the above listed hospital and/or physician. THE DETERMINATION OF ACTUAL BENEFITS..... can only be made upon receipt of the completed claim. Payment for the services received is subject to statutory limitations. Eligibility is dependent upon: 1. the medical necessity for the services provided; and 2. the work-relatedness of the illness or injury. IF THE CLAIMANT REQUIRES CONTINUED HOSPITALIZATION BEYOND THE NUMBER OF DAYS APPROVED..... the admitting physician or authorized hospital representative should contact the carrier/self-insured employer at (phone number) on or before the above days expire. BENEFITS FOR SERVICES RENDERED DURING ADDITIONAL HOSPITAL DAYS NOT CERTIFIED MAY BE DENIED.

iii. Exhibit 3-B, Pre -Admission Denial Letter

Re: Patient: Pre-Certification No.: Contract No.: Date of Service: Hospital: Dear (claimant/physician/provider) The medical director for (carrier/self-insured employer) has carefully reviewed the pre-certification request for admission to the hospital referenced above. Based upon information obtained, it has been determined that the medical necessity of the admission has not been documented. As a result of the findings, this letter is to notify you that (carrier/self-insured employer) will not consider payment for the requested admission. If you disagree with this decision, you may appeal in accordance with the guidelines attached. Sincerely,

2. Implementation

a. Telephone Inquiry Service. Telephone numbers should be published in educational materials and standardized form letters to the physicians, hospitals, and claimants. This telephone service allows for prompt response to requests for review and to general inquiries about the review process.

b. Appropriate Staff and Documentation for Program Management of Certified, Denied and Appealed Admissions. Registered nurses and physicians are the recommended staff for processing of pre-admission certification requests and inquires. Procedures must be available for timely review of appealed or denied admissions by a physician (a psychiatrist for mental illness or substance abuse admissions). Program procedures should be routine and documented.

3. Evaluation

a. Data Collection. Pre -admission certification documentation should be linked to the payment system to properly process inpatient claims. The pre-admission certification documentation should be retrievable on a claim-by-claim basis for compilation and classification of activity performance.

b. Carrier/Self-Insured Employer Data Reporting. Carrier/self-insured employer will be required to collect the following data according to the Office of Workers' Compensation Administration requirements.

Information	Positions	Type
ICD-10-CM	5/7	Numeric
Provider Name	30	Alpha
Provider Street Address	30	Alpha Numeric
Parish Code for Provider of Service (Use Standard FIPS code, see Exhibit 5)	3	Numeric
Place of Treatment	1	Alpha Numeric
Type of Facility*	6	Numeric
Type of Service: Medical vs. Surgical	1	Alpha Numeric
Claimant Name	30	Alpha
Claimant Social Security Number	9	Numeric
Length of Stay	4	Numeric
*See "Type Facility Codes" in Exhibit 6.

c. Exhibit 5

F.I.P.S. Area Codes
001 Acadia	045 Iberia	089 St. Charles
003 Allen	047 Iberville	091 St. Helena
005 Ascension	049 Jackson	093 St. James
007 Assumption	051 Jefferson	095 St. John the Baptist
009 Avoyelles	053 Jefferson Davis	097 St. Landry
011 Beauregard	055 Lafayette	099 St. Martin
013 Bienville	057 Lafourche	101 St. Mary
015 Bossier	059 La Salle	103 St. Tammany
017 Caddo	061 Lincoln	105 Tangipahoa
019 Calcasieu	063 Livingston	107 Tensas
021 Caldwell	065 Madison	109 Terrebonne
023 Cameron	067 Morehouse	111 Union
025 Catahoula	069 Natchitoches	113 Vermillion
027 Claiborne	071 Orleans	115 Vernon
029 Concordia	073 Ouachita	117 Washington
031 De Soto	075 Plaquemines	119 Webster
033 East Baton Rouge	077 Pointe Coupee	121 West Baton Rouge
035 East Carroll	079 Rapides	123 West Carroll
037 East Feliciana	081 Red River	125 West Feliciana
039 Evangeline	083 Richland	127 Winn
041 Franklin	085 Sabine
043 Grant	087 St. Bernard	998 Out-of -State

d. Exhibit 6a

Type Of Facility Code General Type Provider (Position 1 and 2)
00	Not Licensed	36	Alcohol/Drug Rehab Center (CDU)
01	Hospital*	37	Special Care Unit-Behavior Modification
02	Skilled Nursing Facility*	38	Outpatient Surgical Unit (Hospital Based)
03	Custodial Nursing/Rehab Facility	39	Hospice
04	Physician (M.D.)	40	Licensed Massage Therapist (MA)
05	Home Health Agency*	41	Doctor of Education (EdD)
06	Dentist (D.M.D.-D.D.S.)	42	Lithotripter Facility
07	Pharmacy (not hospital)	43	Master of Science (M.S.)
10	Ambulance (non -hospital)	44	Certified Substance Abuse Counselor (CSAC)
11	Podiatrist (D.P.M.)	45	Counseling and Biofeedback Therapy
12	Psychologist (Ph.D.)	46	Family Counseling, Pastoral Counseling
13	Chiropractor	47	Oriental Medical Doctor (O.M.D.)
14	Osteopath (D.O.)	48	Certified Surgical Technician (C.S.T.)
15	Registered Nurse (R.N.)	49	Doctor of Divinity (D.D.)
16	Surgical Center (free standing)	50	Private Duty Nursing
17	Radiation Center (free standing)	51	Multiple Specialties
18	Renal Dialysis Center (free standing)	52	Radiology (Non-Hospital)
19	Certified Registered Nurse Anesthetist (CRNA)	53	VA/Military Hospital/ Acute Care
20	Physical Therapist	54	VA/Military Hospital/ Psychiatric
21	Optometrist	55	VA/Military Hospital/CDU
22	Registered Sitter	56	VA/Military Hospital/SNF
23	Optical Dispensary	57	VA/Military Hospital/HHA
24	Medical/Surgical Supply Organization	58	VA/Military Hospital/ Ambulatory Surgery
25	Other Para-Medical	59	Registered Dietitian (R.D.)
26	Hearing Aid Dealers	60	Cardiac Catherization Facility
27	Audiologist	61	Residential Treatment Center
28	Speech Pathologist	62	Eating Disorder Treatment Facilities
28	Social Worker	63	Physician's Assistant
30	Licensed Practical Nurse	64	Third Party Liability
31	Public Conveyance	65	Emergency Room Physicians
32	Rehabilitation Center	66	Medical Staff Services
33	Pre-admit Testing Facility	67	Mental Health Clinic
34	Alcohol/Drug Rehabilitation Center (CDU) Detox Services Only	68	Sperm Banks
35	Psychiatric Hospitals-Inpatient and Outpatient	69	Home Infusion Therapy
	*If position 1 and 2 are 01, 02, or 05, use the additional codes on the next page, otherwise, the remaining four positions of the Type Facility Code may be filled with zeros (0's).

e. Exhibit 6b

Type of Facility Code
Specific Type Provider (Position 3 and 4)
If General Type (Position 1 and 2) is 01:
01	General Short Term	03	Official Health Agency
02	General Long Term	04	Rehab. Facility Based Program
03	TB	05	Hospital Based Program
04	Psychiatric	06	S.N.F. Based Program
05	Chronic Disease	07	Proprietary
06	Specialty Short Term	08	Other
07	Specialty Long Term	Ownership/Management (Position 5 and 6)
08	Christian Science	If General Type (Position 1 and 2) is 01 or 02 or 05:
09	All Others	01	Church
If General Type (Position 1 and 2) is 02:		02	Other Than Church
01	Skilled Nursing Facility	03	Proprietary
02	E.C. Unit of Hospital	04	State
03	E.C. Unit of Rehabilitation Center	05	Parish (County)
04	E.C. Unit of Domiciliary Institution	06	City
05	Distinct part of S.N.F.	07	City-Parish (County)
06	Christian Science	08	Hospital District
07	Combined with Intermediate Care	09	P.H.S. (Fed. Gov't.)
08	Intermediate Care Facility Only	10	Other than P.H.S. (Fed Gov't.)
09	Other	11	All Other
If General Type (Position 1 and 2) is 05:		12	Nonprofit
01	Visiting Nurse Association
02	Combined Govt. and Vol. Agency

La. Admin. Code tit. 40, § I-2705

Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991), Amended by the Workforce Commission, Office of Workers' Compensation Administration, LR 42284 (2/1/2016).

The telephone number for the Office of Workers' Compensation has been changed to (225) 342-7555.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.