Clinical Notification Triggers

The clinical notice form should be used by the medical management staff to notify Summit Re of potential cases where Summit ReSources may be of assistance to you. Use the clinical notification triggers list as a guide. The list is not all inclusive, so feel free to submit a clinical notification on any case for which Summit Re may be of assistance to you.

Diagnosis

  • High cost pharmacy, such as Flolan, Factor VII, Factor VIII, Cerezyme / ICD-9: 272.7, 286.0, 415.0, 416.0, 416.8 
  • Major burns with a potential for a prolonged hospitalization / ICD-9: 941.0, 942.0, 943.0, 945.0, 948.2-9
  • ESRD/dialysis with monthly dialysis costs greater than $10,000 / ICD-9: V56.0, V56.8, V45.1 
  • Major injuries or multiple trauma with a potential for a prolonged hospitalization and/or acute rehabilitation admission
  • Premature infants with one or more of the following:
    • gestational age ≤ 24 weeks / ICD-9: 765.0 
    • severe congenital heart disease, e.g. hypoplastic left heat, Tetralogy of Fallot, etc. / ICD-9: 746.7, 746.01, 746.89, 745.2
    • severe gastrointestinal anomalies, e.g. gastroschisis, omphalocele, necrotizing enterocolitis, short bowel syndrome, etc. / ICD-9: 756.79, 777.5, 777.8, 579.3, 756.79
    • severe bronchopulmonary dysplasia requiring long term ventilator treatment / ICD-9: 770.7

Case Characteristics

  • Out of network services with minimal or no negotiated discounts
  • Billed charges that greatly exceed reasonable and customary for the services rendered – refer before the claim is paid
  • Questionable charges, such as unbundling or experimental treatments
  • Cases with the potential to exceed the reinsurance deductible
  • Multiple inpatient stays

Submission Process for Clinical Notices

  1. Use the clinical notification triggers list as a guide for completion of clinical notifications submitted to Summit Re.
  2. It is recommended that the clinical notices be submitted from the medical management department as they are usually the department first notified of a request for services.
  3. Complete the Clinical Notification Form (all sections that apply to your case).
  4. Completed forms may be faxed to 260-469-3014, emailed via encrypted software to claims@summit-re.com, or mailed to Summit Reinsurance Services, 7030 Pointe Inverness Way, Suite 350*, Fort Wayne, IN 46804.
  5. In lieu of the clinical notification form, you may submit a report containing similar information.

*Address updated when this article was converted to this post in 2014.

Early Intervention Goal of New Clinical Notice Process

To better assist you in managing your risk and to minimize paperwork, Summit Re has significantly revised the notification process for high cost, catastrophic cases. The main goal of the revised process is to help you manage your risk while there is an opportunity to intervene. Under the current HMO reinsurance agreements, clients are required to notify Summit Re of members whose eligible expenses have reached 50% of the deductible. Currently, Summit Re receives the majority of the 50% notices from finance or claims departments. By this time, the claims have already been paid by you, and it is usually too late to implement any additional interventions that may help mitigate costs, as illustrated in the two examples below.

Summit Re will no longer require submission of a 50% notice report from the finance/claims area. Instead, we are requesting clinical notices from the medical management department. The clinical notices will be much more actionable, since services may still be in the pre-service negotiation phase, the case may be undergoing concurrent review and claims have not yet been paid.

As reinsurance agreements are renewed, the language regarding 50% notices will be revised to reflect the new process. The revised referral trigger list (CLICK HERE) keeps the focus on situations where Summit Re may be of assistance to you.

late notification

Reduce Costs With Case Management Notices

When members reach 50% of the reinsurance deductible, according to the reinsurance agreement, we must be notified. The issue is timing. The finance or claims department sends notices based on claims received and/or paid, but often bills are not submitted by the medical facility until the member is discharged, after the claim has reached or exceeded the 50% level. Summit ReSources would like to help reduce your costs; however, once claims are paid, it is harder to intervene with cost-reducing strategies. Usually your medical management department is aware of a potentially high-cost case because the utilization management staff are following the progress of the member and authorizing continued services. Summit Re has developed a case management notification process so that utilization management staff and case managers can notify us of potentially catastrophic, high-cost cases as soon as possible.

All of the case management notices received are reviewed by Debbie Stubbs, RN, MS, CCM to determine if there are ways to reduce cost while maintaining quality of care. Debbie will contact you to offer recommendations and alternatives.

Cases may also be referred even if there is little potential for reinsurance reimbursement if you want an objective, third-party review. Below are actual cases that were recently referred to Summit ReSources.

We are committed to helping you find cost-effective solutions. Regardless of whether the reinsurance deductible is expected to be exceeded, we encourage you to submit case management notices so we can put our resources to work for you. We have a form that can be used but will accept information in any format that works best for you. If you would like a copy of the case management notification form, please contact Debbie Stubbs.

Case Management Example 1

A member requested to go to a specific facility for cancer treatment. The facility was not in the health plan’s network but the request was approved. Global Claim Services, Inc. contacted the facility prior to services being rendered and negotiated a discount for the health plan.

Case Management Example 2

A member required surgery for congenital heart disease and the plan did not have a facility nearby that performed the necessary surgery. Summit ReSources provided the plan with   information about centers with the most favorable outcomes.

Case Management Example 3

A severely burned member was facing a lengthy hospitalization with a complex treatment plan. Paradigm Health provided an assessment by physicians and nurses highly experienced in the care of burn patients and developed a plan of care in conjunction with the treating team.