Inhaled nitric oxide reviews for diagnosis-related group admissions
The purpose of this notification is to inform participating hospitals that the use of inhaled nitric oxide (iNO) during an inpatient stay will be reviewed for medical necessity using our Clinical Utilization Management (UM) Guideline for Inhaled Nitric Oxide, CG-MED-69. iNO is a covered service for eligible members when the use of iNO meets medical necessity criteria. To view the Clinical UM Guideline for INO, visit our www.empireblue.com/nymedicaiddoc.
This also requires that the facility notify Empire BlueCross BlueShield HealthPlus (Empire) of the use of iNO during the course of an inpatient review, and it must be reviewed and approved at some point prior to discharge to avoid exclusion of charges for iNO from the claim payment. If we are not alerted to the use of iNO and, therefore, medical necessity cannot be determined, and charges for iNO are included in the claim submission, the charges for iNO will not be considered in calculation of reimbursement for the stay.
When iNO is used, providers are required to submit an itemized list of charges with the claim for the inpatient stay.
Impact on the diagnosis-related group (DRG) payment
The charges for iNO that are determined to be not medically necessary will not be considered and could impact the DRG outlier payment, as the stay may not reach outlier status as soon as it would with inclusion of these charges. If the case reaches the outlier threshold, we will adjudicate the claim consistent with the financial terms of the contract for outliers, without inclusion of charges for iNO that are not medically necessary or the use of which was not disclosed.
Providers should direct questions regarding this guideline or in relation to the Utilization Management review process to the health plan numbers listed below:
Providers should fax new prior authorization requests for physical health inpatient services to 1-866-494-5635.
Fax submissions of clinical documentation as requested by the Empire Inpatient Utilization Management department supporting medical necessity reviews for inpatient concurrent reviews to 1-866-494-5635.
November 2020 Empire Provider News