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Preauthorization, Notice Requirements from NYS DFS Insurance Circular Letter #17

Audience: Hospitals, Inpatient Mental Health Facilities, Skilled Nursing Facilities, Home Health Care Providers

Univera Healthcare has implemented the requirements included in the New York State Department of Financial Services’ (NYS DFS) Insurance Circular Letter No. 17 (2020) issued December 23, 2020 for its commercial and Safety Net lines of business. In addition, Univera Healthcare has voluntarily extended Circular Letter No. 17 requirements to its Medicare line of business.  

The requirements of Circular Letter No. 17 are summarized below, but we encourage you to review the document in its entirety for additional information.  

While self-funded accounts are beyond the scope of this NYS DFS Circular Letter, we are in discussions with self-funded groups regarding the implementation of similar changes for their members and will keep you informed of any developments. 

Beginning December 23, 2020 through February 21, 2021 (end date subject to extension by NYS), the following provisions are in place: 

  • Suspension of preauthorization requirements for scheduled inpatient surgeries,  inpatient mental health services, hospital admissions, inpatient rehabilitation and in-network home health care services following an inpatient hospital stay.    
     
  • Suspension of preauthorization requirements for transfers between hospitals.  Preauthorization will continue to be required for non-emergency air transport.

    Please note:
    • Preauthorization is suspended for urgent or non-elective scheduled inpatient surgeries or inpatient admissions at hospitals. 
    • This suspension of preauthorization review does not apply to “non-essential elective procedures” that can be delayed in accordance with the NYS Department of Health directive dated April 29, 2020. Non-essential elective procedures include those described in Tiers 1a and 1b of Attachment A of the NYS DOH directive and in Tiers 2a and 2b of Attachment A if, in the clinical judgement of the patient’s physician, a delay will not worsen the patient’s morbidity or impact mortality. Please refer to the link below for Attachment A of the NYS DOH directive (see pg. 5).       
    • Hospitals are strongly encouraged to provide notification to us within 48 hours of an admission so that we can assist with discharge planning and coordination of care.
    • Hospitals should use best efforts to transfer Univera Healthcare members to in-network providers.
    • Univera Healthcare reserves the right to perform concurrent and/or retrospective reviews.
    • Concurrent review and retrospective review will be conducted for non-COVID inpatient care, skilled nursing facilities and home care services following a hospital discharge.
       
  • Retrospective medical necessity denials prohibited for COVID-19 emergency department and inpatient hospital services. 
     
  • Emergency admission timely notification requirements have been lifted. Univera Healthcare will not issue a denial solely on the basis that the hospital did not provide notification. 
     
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