La. Admin. Code tit. 40 § I-2705

Current through Register Vol. 50, No. 9, September 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)
00Not Licensed36Alcohol/Drug Rehab Center (CDU)
01Hospital*37Special Care Unit-Behavior Modification
02Skilled Nursing Facility*38Outpatient Surgical Unit (Hospital Based)
03Custodial Nursing/Rehab Facility39Hospice
04Physician (M.D.)40Licensed Massage Therapist (MA)
05Home Health Agency*41Doctor of Education (EdD)
06Dentist (D.M.D.-D.D.S.)42Lithotripter Facility
07Pharmacy (not hospital)43Master of Science (M.S.)
10Ambulance (non -hospital)44Certified Substance Abuse Counselor (CSAC)
11Podiatrist (D.P.M.)45Counseling and Biofeedback Therapy
12Psychologist (Ph.D.)46Family Counseling, Pastoral Counseling
13Chiropractor47Oriental Medical Doctor (O.M.D.)
14Osteopath (D.O.)48Certified Surgical Technician (C.S.T.)
15Registered Nurse (R.N.)49Doctor of Divinity (D.D.)
16Surgical Center (free standing)50Private Duty Nursing
17Radiation Center (free standing)51Multiple Specialties
18Renal Dialysis Center (free standing)52Radiology (Non-Hospital)
19Certified Registered Nurse Anesthetist (CRNA)53VA/Military Hospital/ Acute Care
20Physical Therapist54VA/Military Hospital/ Psychiatric
21Optometrist55VA/Military Hospital/CDU
22Registered Sitter56VA/Military Hospital/SNF
23Optical Dispensary57VA/Military Hospital/HHA
24Medical/Surgical Supply Organization58VA/Military Hospital/ Ambulatory Surgery
25Other Para-Medical59Registered Dietitian (R.D.)
26Hearing Aid Dealers60Cardiac Catherization Facility
27Audiologist61Residential Treatment Center
28Speech Pathologist62Eating Disorder Treatment Facilities
28Social Worker63Physician's Assistant
30Licensed Practical Nurse64Third Party Liability
31Public Conveyance65Emergency Room Physicians
32Rehabilitation Center66Medical Staff Services
33Pre-admit Testing Facility67Mental Health Clinic
34Alcohol/Drug Rehabilitation Center (CDU) Detox Services Only68Sperm Banks
35Psychiatric Hospitals-Inpatient and Outpatient69Home 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.