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Inpatient Financial Penalties:

Notification

No Notification

Late Notification

Definition

Notification that occurs after discharge or when no notice is received by Intracorp for an inpatient admission.

Notification that occurs:

  • less than 5 days prior to the admission date, but prior to discharge for a non-emergency admission; or,

  • 48 hours after admission, but prior to discharge for an emergency or maternity admission.

Penalty

A $500 penalty will be imposed if the inpatient admission is later found to be medically necessary. A $250 penalty will be imposed if the inpatient admission is later found to be medically necessary.

Specified Outpatient Diagnostic Tests The following outpatient tests require certification by Intracorp prior to services being rendered:

  • CAT Scan – excluding brain and head scans (visual x-ray of soft tissue/bones; specialized x-ray visualization of the body structures)

  • Colonoscopy – (internal visualization of colon/lower intestinal tract using lighted instrument for diagnosis or treatment)

  • MRI Scan – excluding brain and head scans (magnetic imaging of body structures)

  • UGI Endoscopy/EGD (internal visualization of the stomach-upper intestinal track using lighted instrument for diagnosis or treatment)

Notification Requirements for Outpatient Diagnostic Tests

Non-emergency

Emergency

As soon as possible, but at least 48 hours prior to test being performed Within 48 hours of test being performed

If the participant fails to meet the notification requirements, penalties will be imposed if the test is later found to be medically necessary by Intracorp.

Notification

Definition

Penalty

No Notification

Notification that occurs any time notice is given to Intracorp 48 hours after an emergency test is performed or any time after a non-emergency test is performed.

A $100 penalty will be imposed if the outpatient service is deemed medically necessary based on retrospective review.

Outpatient Financial Penalty:

37

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