On March 26, 2020, the Insurance and Safety Fire Commissioner issued Directive 20-EX-7 regarding the coronavirus (COVID-19) pandemic. The directive is issued to all insurers authorized to write accident and health insurance and health benefit plans in the state.
The directive is released as part of the state's public health emergency response to mitigate the spread of COVID-19. The guidance recognizes that as hospitals face high demands for in-patient services and use available staff to provide direct patient care, administrative functions may need to be limited.
Accordingly, the guidance advises insurers that certain utilization review and notification requirements should be suspended for 60 days, subject to further evaluation as the COVID-19 situation evolves.
Specifically, the directive suspends preauthorization requirements for scheduled surgeries or admissions at hospitals. Instead, hospitals are asked to use their best efforts to provide 48 hours' notice to issuers after a hospital admission. Similarly, issuers are advised to suspend concurrent reviews for inpatient services as well as retrospective reviews for inpatient services and emergency services at in-network hospitals. In order to allow hospitals to discharge patients to lower levels of care as appropriate, the insurers are further advised to suspend preauthorization requirements for post-acute placements, including skilled nursing facilities, home health care facilities, acute rehabilitation services, and long-term acute care hospitals, following an inpatient hospital admission.
Issuers are asked to pay claims from in-network hospitals that are otherwise eligible for payment as soon as possible and without reviewing for medical necessity. However, a retrospective review may be performed following the suspension and taking into account the circumstances involving the COVID-19 pandemic. Nonessential audits of hospital payments should also be temporarily suspended.
The memo is directed at insurers authorized to write insurance in the state. Additionally, third party administrators are encouraged to apply these provisions to their service arrangements with self-funded plans. Employers should also be aware of these developments.
Directive 20-EX-7 »