Use Management Requirements for Atripla

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ProgenyHealth Neonatal Intensive Care Program Update and Reminders

We would like you to be aware that our Neonatal Intensive Care Program in partnership with ProgenyHealth, Inc., an independent company, will soon be available to an additional number of our members, some of whom may be your patients.

As always, be sure to check member benefits and eligibility at HealtheNet.com prior to delivering services to our members.

Upon the hospital notification to Univera Healthcare of a member admission to the NICU, ProgenyHealth will initiate the concurrent review process to monitor the medical necessity and appropriateness of level of care. ProgenyHealth supports the process for discharge planning and provides case management services for the first year of life. The family will have 24/7 access to a ProgenyHealth nurse care manager who will provide education and support as needed. Please review the following reminders:

Inpatient Reviews

  • Upon notification to Univera Healthcare, ProgenyHealth contacts the hospital utilization management nurses to conduct the inpatient reviews. ProgenyHealth does not contact the hospital’s NICU nurses directly.
  • Medical necessity determinations for inpatient care are based on clinical status and guidelines using the application of evidence based national criteria. Experienced neonatologists are actively engaged in this process. Reviews will be conducted by telephone or fax during normal business hours.
  • Our standard appeals process applies. Please refer to the Univera Healthcare Participating Provider Manual at provider.univerahealthcare.com for further information.
  • ProgenyHealth will:
    • manage NICU transfers
    • facilitate discharge planning, including home care and DME pre-authorizations, if required
    • manage all hospital readmissions for the first year of life

Case Management Services

  • ProgenyHealth’s case management staff will begin contact with the family while the infant is inpatient and will continue to be engaged with the infant and family for the first year of life, assisting with coordination of care while the infant is home. If indicated, ProgenyHealth may contact the infant’s primary care physician.
  • When an infant is readmitted to the hospital within the first year of life, ProgenyHealth will continue to provide care management services that include a nurse case manager’s engagement. The authorization process will remain the same for readmissions.
  • If the infant requires case management services after his/her first birthday, ProgenyHealth will transfer case management services to the Health Plan.

We hope that you find this information helpful. Remember, as always, that failure to obtain preauthorization or to comply with your participation agreement or our member contract requirements, or utilization management policies and procedures, may result in a claim denial.
If you have questions, contact your Provider Relations representative.

 
 
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