March 2, 2023
Inpatient admission notification isn’t a substitute for prior authorization. Some services require prior authorization in addition to admission notification and some services don’t require admission notification at all. It all depends on the type of admission and facility.
| Type of admission or facility |
What’s required, what you need to know |
| Acute care hospital |
Inpatient admission notification is required for all acute care hospital admissions and discharges within 24 hours of admission. The admission requires medical necessity review. The request for medical necessity review can be initiated by submitting clinical records by either:
- Submitting an inpatient notification request through Availity (this provides the fastest response).
- Submitting an admission/concurrent review fax form.
- Using HIE (Health Information Exchange), available to Washington state facilities. Note: You'll need to submit clinical records through Availity.
|
| Free-standing psychiatric hospital |
Inpatient admission notification is required for all free-standing hospital psychiatric admissions and discharges. This service requires medical necessity review. The request for medical necessity review can be initiated by submitting clinical records by either:
|
Intermediate levels of care
Long-term acute care hospital (LTAC)
Inpatient rehabilitation facility/unit (IPR)
Skilled nursing facility (SNF)
Residential treatment center (RTC) |
Medical necessity prior authorization is required. The request for prior authorization can be initiated by submitting clinical records by either:
|
| Maternity |
Inpatient admission notification is not required for the first 48 hours for vaginal delivery and the first 96 hours for cesarean delivery.
Inpatient admission notification is required for anything beyond these time frames. The request for medical necessity review can be initiated by submitting clinical records by either:
|
| NICU (Neonatal Intensive Care Unit) |
Inpatient admission notification is not required for babies admitted to a NICU. |
| Observation status admissions |
Admission notification and prior authorization are not required for observation stays, even if greater than 23 hours.
If the patient’s status changes from observation to inpatient, admission notification review is required within 24 hours of admission. The request for medical necessity review can be initiated by either:
|
| Prior authorization for planned procedures, surgeries |
All planned procedures, surgeries, and other services require prior authorization and/or medical necessity review and inpatient admission and discharge notification. View our code list for requirements.
If your planned procedure requires notification or prior authorization for medical necessity review, it can be initiated by submitting clinical records by either:
|
This doesn't apply to Medicare Advantage members. Learn more about inpatient admission notification for Medicare Advantage members.