Ambetter of North Carolina Inc. Elective Medical Inpatient Authorization Process Change Effective May 1st, 2024

Date: 03/01/24

To provide increased flexibility and better align with industry best practices, we are making the following changes to our elective medical inpatient authorization process effective May 1st, 2024.

Ordering Providers:

• Prior authorizations for elective inpatient services will be approved for professional services by issuing an outpatient (OP) authorization.
  • Elective Inpatient Prior Authorization numbers will now start with the prefix of OP instead of IP (i.e., OP123456789). 
  • Physicians may request Prior Authorization via phone, fax, or secure provider portal. See the Provider Authorization Guide for details.
  • The authorization details will indicate approval at the inpatient level of care.Authorization time spans will not change. 
  • Failure to request timely prior authorization may result in a denial of payment.

Inpatient Facilities:

• Authorizations for the elective inpatient stay (IP authorization) will be processed and issued at the time of admission.
  • There is no need to get an IP authorization for the elective inpatient stay prior to the date of admission. Notification of admission is required within one business day of admit.
  • Notification of admission can be completed using any one of the Prior Authorization methods; phone, fax, or secure portal.  See the Provider Authorization Guide for details.
  • At the time of admission notification, a new authorization number for the admission will be provided with the IP prefix (IP Authorization).
  • Services can be rendered any time within the authorization time span.
  • Failure to provide timely notification may result in a denial of payment for the submitting facility

As a reminder, all planned/elective inpatient services require prior authorization. Prior authorization should be requested at least five (5) days before the scheduled service delivery date or as soon as need for service is identified. If prior authorization is not on file at the time of elective admission and there is an extenuating circumstance, the service is considered retrospective, and provider should follow the appropriate retrospective request process. Emergent admissions do not require prior authorization.

Thank you for continuing to provide our members with high quality and compassionate care. If you have questions regarding the information contained in this update, please contact your Provider Engagement Administrator. If you need your assigned Provider Engagement Administrator contact information, please visit: network.carolinacompletehealth.com/engagement