Attention: CA/WA/OR Hospital Providers & All Hospital Providers with VA, Medicare, or Medicaid Patients

In response to growing demands, ERN has revamped tools in its latest version of REVAssurance to assist our provider members. The following letters have been added/updated:

California

1. [Fax Cover] Request for Post-Stabilization Authorization
2. [Fax Cover] Notification of Disagreement of Care
3. [Fax Cover] COHS – Request for Authorization

Washington

1. [Fax Cover] Request for Post-Stabilization Authorization
2. [Fax Cover] Competent Reviewer Request

Oregon

1. [Fax Cover] Request for Post-Stabilization Authorization
2. [Fax Cover] Competent Reviewer Request
3. [Fax Cover] Notification of Disagreement of Care

Veteran Affairs (VA)

1. [Fax Cover] Request for ER Authorization

Medicaid & Medicare

1. [Fax Cover] Notification of Disagreement of Care

These new and/or updated fax cover sheets have been redesigned for readability, legibility, and brevity. Where possible, we have condensed different jurisdictions’ laws into one fax cover sheet and included check-boxes for your staff to identify the correct jurisdiction. All fax cover sheets have been standardized to ensure conformity with current laws and minimize the amount of work for your staff while maintaining flexibility and customizability.

For newer members who may not be familiar with our fax cover sheets, we provide a brief explanation of each type below:

A Request for ER or Post-Stabilization Authorization is used to request authorization for ER or post-stabilization services. While your staff are already familiar with this procedure, they may not know that some jurisdictions have legally mandated timeframes to respond to such requests. We encourage your staff to pay attention to these timeframes, as non-compliance can be used as a basis to appeal a claim or even demand an authorization before the patient is discharged.

A Notification of Disagreement of Care is to be used when the health plan has denied an authorization. It serves as a formal memorialization of the denial of services. In some jurisdictions, plans are also required to effectuate a transfer of the patient upon a disagreement of care. Therefore, in these jurisdictions, it is particularly important to have the disagreement of care memorialized in writing, not just for record-keeping purposes but also to prove non-compliance with transfer requirements.

A Competent Reviewer Request is to be used when there is question as to the decision-making of a health plan’s medical director to deny your patient’s care. Many jurisdictions do not have a legally mandated right to such a request. However, where allowed, it offers your staff the ability to dispute the medical necessity denial and attempt a peer-to-peer earlier.

California Ambulance Providers

On October 10, 2023, Assembly Bill (AB) 716 (Stats. 2023, Ch. 454) was enacted. This bill drastically changed the landscape of ambulance service claims by adding enrollee protections against balance billing for noncontracted ground ambulance services and creating a bona fide reimbursement methodology for select counties. California Health & Safety Code § 1371.56, one of the laws added by AB 716, requires ambulance services to be directly reimbursed for the difference between the in-network cost-sharing amount and the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea. Accordingly, the legal rates established by the City of Los Angeles in LA City Ordinance (#185210) are now binding upon health plans. As such, the following letters: (1) CA HMO Affidavit – LA City Ambulance Transport No Contract Underpayment, and (2) CA HMO Appeal – LA City Ambulance Transport No Contract Underpayment have been updated on REVAssurance to reflect these changes.

Issues concerning contracted ambulance provider claims being denied for lack of authorization after the capitated provider requests pick-up have also been recently brought to our attention. To help you fight these denials, we have updated REVAssurance to include a sample appeal letter (CA HMO Appeal – Ambulance Transport Contract No Auth Improper Notice) as well as:

1. [Fax Cover] Request for Authorization
2. [Fax Cover] Request for Reconsideration