Authorization Notification Timelines
Date: 07/23/20
Heritage Health (Medicaid):
The Nebraska Total Care Provider Manual includes authorization notification timelines for providers to reference. To support ongoing visibility to these timelines Nebraska Total Care is posting the table below from the Provider Manual.
Authorization must be obtained prior to the delivery of certain elective and scheduled services. The following timeframes are required for prior authorization and notification:
| Service Type | Timeframe |
|---|---|
| Scheduled admissions | Prior authorization required five business days prior to the scheduled admission date |
| Elective outpatient services | Prior authorization required five business days prior to the elective outpatient admission date |
| Emergent inpatient admissions | Notification within two business days |
| Observation | Notification within one business day for non-participating providers (all observation services for non-participating providers require authorization) |
| Unplanned Observation – greater than 23 hours | Requires inpatient prior authorization within one business day |
| Planned Observation – greater than 23 hours | Prior authorization required five business days prior to the scheduled service admission date |
| Emergency room and post stabilization, urgent care and crisis intervention | Notification within two business days |
| Maternity admissions | Notification within one business day, with delivery outcome |
| Newborn admissions | Notification within one business day |
| Neonatal Intensive Care Unit (NICU) admissions | Prior authorization within one business day |
| Behavioral Health Services | See “Inpatient Notification Process” |
Any prior authorization request that is faxed or sent via the website after normal business hours (Monday – Friday 8 a.m. to 5 p.m. CST, excluding holidays) will be processed the next business day.
Failure to obtain authorization may result in administrative claim denials.
As an additional reminder, Nebraska Total Care will not retroactively authorize routine services, except in cases where one of the valid extenuating circumstances is documented:
- Services authorized by another payor who subsequently determined member was not eligible at the time of services
- Member received retro-eligibility from Department of Health and Human Services, Division of Medicaid and Long-Term Care
- Services occurred during a transition of care period between two Heritage Health Managed Care Organizations
- Member was not capable of providing insurance information due to incapacitation
If you have questions please reach out to Provider Relations.