Place of Treatment - Outpatient

Many inpatient procedures may be safely and effectively performed in an ambulatory surgical center (ASC) or other outpatient setting without compromising the quality of patient care. HMSA encourages providers to review the attached list of recommended outpatient procedures. (See Place of Treatment - Outpatient Procedures List) These services are eligible for benefit coverage under HMSA plans only when performed in an ASC or lower-level setting such as a physician's office, unless the physician has contacted HMSA to precertify benefit coverage in a more acute setting (e.g., inpatient hospital).

It is understood that common standard of care practices will be followed, and equipment, instruments and facilities should be properly maintained and periodically inspected to ensure the safety of HMSA members.

Precertification of Inpatient Services

HMSA will evaluate precertification requests and respond to the physician within 15 calendar days of receipt of all necessary information. For urgent precertifications, a decision will be made and communicated to the physician within 72 hours from the receipt of the request or 48 hours after the earlier of a) our receipt of additional necessary information or b) the deadline we specify for the additional necessary information to be provided.

If a physician is recommending that an outpatient procedure be performed in an inpatient setting, the physician should submit a precertification request to HMSA's Precertification Unit. When requesting precertification, the physician should outline their concerns about the member's comorbidities, complex problems, age considerations (e.g., younger than 1, older than 70), etc.

HMSA will evaluate precertification requests and respond to the physician within 15 calendar days of receipt of all necessary information. For urgent precertifications, a decision will be made and communicated to the physician within three calendar days of receipt of all necessary information.

To precertify benefits for procedures performed in an inpatient setting, please contact the Precertification Unit (HMSA Directory - Provider Resources). If you call after hours, please leave a voice mail message.

If the request for inpatient benefits is denied, the physician may appeal the decision by calling the Precertification Unit (HMSA Directory - Provider Resources). HMSA physician reviewers are available to discuss utilization management decisions with the treating physician. (For more information, see Appealing a Pre-Certification Denial.)

Exceptions

Precertification is not required if:

• A listed procedure is performed in the recommended setting.
• Services are performed in the emergency room.
• The patient is already hospitalized.
• The patient is undergoing a different procedure appropriate to the acute setting, and the listed procedure is being performed at the same time.

Financial Responsibility

If precertification is not obtained, the facility is liable for the non-covered charges. The facility can only bill the member if the member has signed a waiver accepting financial responsibility prior to the procedure. If precertification is reviewed but not approved, the member is responsible for the denied charges. Please ensure that your HMSA patient is fully apprised of their financial responsibility.

Revision History