Notification/Precertification Process
To enhance continuity of care for members, and in response to requests from our employer groups, Wellmark Blue Cross and Blue Shield implemented a voluntary inpatient hospital admission notification program for participating hospitals in Iowa and South Dakota beginning January 1, 2007.
The purpose of this notification is to collaborate with the primary care provider in identifying the types of member health support programs appropriate and available for the member following hospitalization. Notification also enables Wellmark to maximize member benefits.
This change does not affect Wellmark’s precertification requirements.
| When Notification Is Requested |
Notify Wellmark within one business day following an inpatient hospital admission for the following types of care.
Wellmark will not provide a validation number for these services because the notification is voluntary. There is no penalty or benefit reduction for noncompliance.
- Acute medical and surgical admissions
- Maternity stays beyond two days for vaginal births and four days for cesarean births
- Extended stays for newborns
Wellmark highly recommends that you continue to notify us of critical care admissions. This includes:
- Medical intensive care unit
- Surgical intensive care unit
- Coronary intensive care unit
- Pediatric intensive care unit
- Neonatal intensive care unit
- Burn intensive care unit
- Inpatient transplant care unit
These admissions may represent more complex discharge needs and opportunities for Wellmark's care management to be involved. Please include the type of intensive care unit on your notification.
| When Precertification Is Required |
Precertify the following services with Wellmark before providing care to avoid a benefit reduction of the lesser of 50 percent or $5,000 for Wellmark members, or a reduction of $500 for a Federal Employee Program (FEP) member.
- Home health
- Home infusion therapy
- Skilled nursing
- Hospice
- Acute rehabilitation
- Precertification is also required for members who are admitted to hospitals outside of Iowa and South Dakota, except for maternity stays.
Use the Notify/Precertify Admissions Blue Connection® tool on www.wellmark.com, or contact Wellmark via phone using the phone number on the back of the member's ID card.
| Notification/Precertification
Chart |
| |
Type of Service or Level of Care |
Notification Requirement
|
| |
Medical and surgical inpatient care |
Notification is requested and no penalty will be assessed. |
| |
Maternity inpatient stays that exceed the two-day vaginal, four-day cesarean delivery time frames and extended inpatient stays for newborns |
Notification is requested and no penalty will be assessed. |
| |
- Skilled nursing care
- Acute rehabilitation care
- Home health services
- Hospice
services
- Home infusion therapy
- Hospital inpatient care outside Iowa and South Dakota (except maternity)
|
Precertification required. Penalties applied:
- 50% or $5,000 for a Wellmark member
- $500 for FEP members
|
BlueCard members' (members who have coverage with Blue Plans other than Wellmark) precertification/notification requirements may vary. Please follow the precertification guidelines for every planned admission, or notification guidelines following an emergency admission, as indicated on the member's ID card.
| Hospitals Outside Iowa and South Dakota |
Precertification is required for members who are admitted to hospitals outside of Iowa and South Dakota, except for maternity stays. Notification is required within 24 hours of an emergency admission.
| When Notification or Precertification Is Not Needed |
Please do not notify Wellmark of the following admissions:
- Medicare Supplement (e.g., Senior Blue) members.
- Obstetrical admissions unless an admission exceeds the two-day vaginal, four-day cesarean delivery time frames, or a newborn experiences an extended stay.
- Outpatient procedures, such as colonoscopies.
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