CHAPTER 13 - SERVICE AUTHORIZATION
13.3 CONCURRENT REVIEW
HCIC uses ADHS/DBHS authorization criteria for concurrent review of prior authorized levels of care
when making hospital length of stay decisions. Information obtained in the decision-making process
includes, but is not limited to symptoms, diagnostic test results, diagnoses, and required services. HCIC
participates in discharge planning for members in institutional settings.
HCIC specifies timeframes and frequency for conducting concurrent review and decisions and provides
these to the requestor and to the facility being authorized:
 Authorization for institutional stays have a specified date by which the need for continued stay
will be reviewed.
 Admission reviews are conducted within one business day after notification is provided to HCIC
by the hospital or institution (this does not apply to precertification) (42 C.F.R. 456.125).
Authorization requests include but are not limited to:
 Necessity of admission and appropriateness of the service setting
 Quality of care
 Length of stay
 Whether services meet the member’s needs
 Discharge needs
 Utilization pattern analysis
Health Choice Integrated Care must also:
 Monitor timeframes and frequency for conducting concurrent review and decisions of acute
levels of care including Skilled Nursing Facility (SNF)
 Track the number of SNF days utilized by a member in a contract year and the process for
intervening with AHCCCS Member Services on day 45 when an ALTCS application is pending
Criteria for decisions on coverage and medical necessity is clearly documented and based on
reasonable medical evidence or a consensus of relevant health care professionals.
•
Medical criteria must be approved by Health Choice Integrated Care’s Medical
Management/Utilization Management (MM/UM) Committee. Criteria must be adopted from
national standards. When providing concurrent review, Health Choice Integrated Care must
compare the member’s medical information against medical necessity criteria that describes the
condition or service.
•
Initial institutional stays are based on Health Choice Integrated Care’s adopted criteria, the
member’s specific condition, and the projected discharge date.
•
Continued stay determinations are based on written medical care criteria that assess the need
for the continued stay. The extension of a medical stay will be assigned a review date each time
the review occurs. Health Choice Integrated Care ensures that each continued stay date is
recorded in the member’s record.
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Last Revised: October, 2015