Hospital Services

• Inpatient Admissions
• Reimbursement
• Hospital Transfer Policy
• Outpatient Surgery Procedures
• Emergency Room
• Ambulance Services

In order for Gateway to monitor the quality of care and utilization of services by our members, all Gateway practitioners are required to obtain an authorization number for all hospital admissions and outpatient surgical procedures by contacting Gateway’s Utilization Management Department at 1-800-392-1146.

Gateway will accept the primary care practitioner, ordering practitioner, or the attending practitioner’s request for an authorization of non-emergency hospital care; however, no party should assume the other has obtained authorization. Gateway will also accept a call from the hospital’s Utilization Review Department.

The Utilization Management Representative refers to the Gateway Physician Advisor if criteria or established guidelines are not met for medical necessity. The ordering practitioner is offered a peer review opportunity with the Gateway Physician Advisor for all potential denial determinations.

Please see the Claims and Billing Section of this Manual for information regarding claims submission.

When a Gateway member requires hospitalization, Gateway’s policy is to have the service rendered in a Gateway participating hospital. However, Gateway recognizes that it may not be possible to follow this general policy when a member presents to the closest medical facility due to a medical emergency. When the medical condition of the member requires an admission to a non-participating hospital, the member will be transferred within twenty-four (24) hours of stabilization, when appropriate.

In order to determine that the member is medically stable for transfer the Gateway Utilization Management staff will concurrently monitor the condition of the patient by communicating with the hospital’s Utilization Review staff and the attending practitioner. Gateway will coordinate all necessary transportation for the timely transfer of the member.

Gateway practitioners may utilize a hospital’s Short Procedure Unit (SPU) or Ambulatory Surgery Unit (ASU) for any authorized medically necessary procedure.

Medical Necessity Reviews may be required for certain procedures. Please call Gateway’s UM Department to verify if authorization is required or refer to the Quick Reference Guide on Gateway’s website.

Should a request to perform an outpatient procedure be denied by Gateway, the practitioner will receive telephonic notification of the denial within twenty-four (24) hours or one (1) business day of the decision. Urgent requests are responded to immediately. Due to monthly changes in member eligibility, Gateway recommends that authorization be requested at least two (2) working days in advance when possible.

The definition of an emergency is: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (b) serious impairment to bodily functions, or (c) serious dysfunction of any bodily organ or part.

The following conditions are examples of those most likely to require emergency treatment:

Gateway members have been informed, through the Member Handbook, of general instances when emergency care is typically not needed. These are as follows:

In all instances, when a member presents to an emergency room for diagnosis and treatment of an illness or injury, the hospital’s pre-established guidelines allow for the triage of illness and injury.

All follow-up care after an emergency room visit must be coordinated through the primary care practitioner. Members are informed via the Member Handbook to contact their primary care practitioner for a referral for follow-up care in instances such as:

Emergencies are handled in the same manner whether in or out of the Gateway service area. Gateway requests that participating practitioners inform Gateway by calling Gateway’s Utilization Management Department whenever they learn that a member has received care outside of the service area.

Emergent transportation (302 or 911), including air ambulance, does not require authorization by Gateway. Gateway considers emergent transportation as transportation that allows immediate access to medical or behavioral healthcare and without such access could precipitate a medical or a behavioral health crisis for the patient. Either a participating or non-participating ambulance provider may render 302 or 911 transportation without an authorization from Gateway.

Gateway also considers the following situations emergent, and thus does not require authorization:

• ER to ER
• ER to Acute Care or Behavioral Health Facility
• Acute Care to Acute Care or Behavioral Health Facility
• Hospital-to-Hospital, when a patient is being discharged from one hospital and being admitted to another.

Providers should bill the above types of transports with the appropriate non-emergent, basic life support code and the modifier HH.

Authorization for non-emergent ambulance transportation is required by Gateway’s Utilization Management Department. Gateway considers non-emergent transportation as transportation for a patient that does not require immediate access to medical or behavioral healthcare and/or if not provided would not result in a medical or a behavioral health crisis as non-emergent. Non-emergent transportation may include the following scenarios:

• Ambulance transports from one facility to another when the member is expected to remain at the receiving facility, which may include the following:
  • Hospital to Skilled Nursing Facility(SNF)
  • SNF to Hospital (non-emergent)
  • Hospital to Rehabilitation Facility
  • Rehabilitation Facility to Hospital (non-emergent)
• Ambulance transport to home upon discharge (if medically necessary and approved by Gateway)

A Gateway participating ambulance provider should be contacted to render non-emergent transportation when possible.

Ambulance transportation from one facility to another for diagnostic testing or services not available at the current facility, with the expectation of the member returning to the original facility upon completion of service, is the responsibility of the originating facility and does not require an authorization from Gateway. The originating facility should assume the cost for this type of transport even if for unforeseen circumstances, the member remains at the receiving facility. The originating facility may contact any ambulance service of their choosing to provide transport in this scenario only.

All wheelchair van transportation requires an authorization from Gateway’s Utilization Management Department.