Authorization Requirements for Inpatient Admissions
DMC Care provides coverage for inpatient admissions. Being admitted to a hospital can be stressful but it is important to remember that DMC Care has specific authorization requirements for inpatient admissions to approve the claims payment.
Elective admissions are prescheduled for surgical or medical procedures and DMC Care requires prior authorization. It is your physician’s or his/her office staff’s responsibility to obtain
authorization prior to the admission. Members must also make sure their doctor has received an authorization from DMC Care for their elective admission.
Urgent and Emergent Admissions
Urgent and emergent admissions are for management of an immediate medical crisis. They are not prescheduled admissions, but DMC Care still requires notification from the hospital prior to admission of the member. It is the hospital’s responsibility to notify DMC Care of the admission.
It is the responsibility of DMC Care Members to make sure they present current ID Cards for all of their medical health plans at the time of admission. DMC Care will provide authorization on the next business day following notification for admissions that meet medical necessity criteria.
DMC Care will make attempts to transfer a member (who is medically stable and in agreement) when he/she is at a hospital that is not in the DMC Care Tier 1 network. This is done in an effort to help reduce the member’s out-of-pocket admission costs.
Remember that only DMC Care can provide authorization of services for DMC Care members. Providers must contact DMC Care as indicated on your ID Card.
DMC Care provides 24 hours, 7 days a week coverage for admissions and transfers. Calls after 5 p.m. are managed by DMC Nurse Triage for inpatient admission notification and assistance with transfers. Prior authorization services are not available after hours.
DMC Care Members and Providers can contact DMC Care Medical Management, Monday - Friday from 8:00 am to 5:00 pm at 1-877-501-0958 for questions and information regarding authorization of services.