Hospital Services
Inpatient Admissions
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. (Refer to the Quick Reference section in this manual for phone number.) In the case of an emergent or urgent admission, the Gateway admitting physician, hospital or member must notify Gateway's Utilization Management Department within one business day of receiving care.
Gateway will accept the primary care practitioner's, ordering practitioner's, 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 and/or policies are not met for a determination.
The ordering practitioner is offered a peer review opportunity with the Gateway Physician Advisor for all potential denial determinations.
During the discharge planning process, if Gateway is notified by the Quality Improvement Organization (QIO) that the member disagrees with the attending physician's discharge, a written detailed notice of discharge will be provided to the member through a process agreed upon by the hospital and Gateway and will be provided to the member within the time-frames established by CMS. (Refer to the Forms and Reference Materials Section of this manual for a Detailed Notice of Discharge.)
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Emergency Room
Members are informed through the Evidence of Coverage how and when to utilize emergency services. Emergency services do not require prior authorization. If a member is unsure whether they need to go to the emergency room they are instructed to call their primary care practitioner for advice.
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Ambulance Services
Transportation by ambulance does not require an authorization when it is emergent or for end stage renal dialysis services. All other non-emergent transportation requires an authorization by Gateway's Utilization Management Department.
Gateway considers emergent transportation as transportation that allows immediate access to medical or behavioral health care 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 when rendered by a Gateway participating ambulance provider:
- 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.
- End Stage Renal Dialysis Center
Providers should bill the above types of transports with the appropriate non-emergent, basic life support code and the modifier HH.
If a non-participating provider renders the above services, an authorization from Gateway is required. Ambulance transportation by non-participating providers to End Stage Renal Dialysis Centers does not require authorization.
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 health care 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 air ambulance services require an authorization from Gateway's Utilization Management Department.
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