EOB -- United
|When a review determines that the criteria for continued stay fails to meet the BJCBH & BHP Level of Care (LOC) guidelines, the provider is notified of the need for information to determine the appropriateness of service. This includes:
The provider supplies the BJCBH & BHP reviewer the clinical information necessary to determine the appropriateness of the continuation of the service within 15 days of receipt of the notification and request; if information is not received within the 15 days, continued authorization for the service is denied.
- Clinical assessment, including presenting problem(s); current symptoms; current emotional, interpersonal and cognitive functioning; support system, prognosis; and recommendations
- Medication changes
- Treatment plan
- Requested authorizations
- Discharge plan
Within 10 days of receipt of the clinical information, a concurrent review is conducted by the UM coordinator using the BJCBH & BHP LOC continued stay guidelines for the specific service under revieWest
If the review determines that continued stay criteria is met, the provider is notified by the UM coordinator within one working day of the decision by telephone or fax; written notification is sent to the provider and client or member within two working days; the written notification includes:
If the review determines that the information provided fails to meet continued stay criteria for the current service, an internal clinical peer review of the case is performed.
- The date of admission and initiation of the service
- The number of units, or sessions, and months authorized
- The service authorized
- The date of the next concurrent review
If a peer review determines that the service continues to be needed, the provider is notified by the UM coordinator.
If a peer review determines that the service fails to meet criteria to continue authorization, the UM coordinator notifies the provider within one working day of the decision by telephone or fax. Written notification is sent to the provider and client within two working days.
Services are provided and authorized to the client without liability until the determination has been made and the client has been notified.