Inpatient Certification

Can Retrospective reviews be completed through Cyber Access?

Retrospective reviews cannot be sent or completed through the application. Providers must mail in complete medical records for review. For Retrospective review questions please call UR Assistant line at (800) 766-0686 Opt. 0.

What telephone and fax number will I use to contact Conduent? And what address will I use to send Retrospective reviews?

To contact utilization review nurses call (800) 766-0686, utilization review assistant (800) 766-0686 Opt. 0, or fax number, (866) 629-0737. The phones are staffed from 8am to 4:30 pm, Monday – Friday, except for holidays. If providers call during off hours or the line is busy, you may leave a message and your call will be returned by the next business day.

Attn: Inpatient Certification Program
3425 West Truman Blvd.
Jefferson City, MO 65109 OR
PO Box 105110
Jefferson City, MO 65110-5110

Do we need to purchase the Milliman criteria to submit our certification requests?

No, the application process will apply the Milliman criteria through the review tool in our system.

If we want to request a reconsideration, can we use Milliman criteria as justification?

Any substantial information showing that Milliman criteria may have resulted in an approval may be sent to the physician reviewing the reconsideration. The physician’s review will be based on his/her professional experience, knowledge and judgment.

Are reconsiderations reviewed based on Milliman’s criteria?

No, the physician reviewing the reconsideration is evaluating the medical necessity based on his/her professional experience, knowledge and judgment.

How will concurrent days be added to a certification?

A Continued Stay request can be submitted through the application and any additional days will be reviewed based on Milliman criteria. When additional days are required, the continued stay requested will have the same certification number through the application.

Will the certification numbers be available electronically through the application?

The web-based process used will provide electronic access to the certifications. A certification number will be provided at the time of approval of stay within the application.

What happens if my requested is pended for utilization review by nurse?

The application will provide a request ID upon completion or submission of all required information for a certification that is pended to utilization nurse review. That request ID can be used to track the status of the stay from submission to certification determination. If the request is approved a certification number will be created and provider notified.

Must the Daily Discharge/Expired Certification report be faxed back to Conduent daily or can we save them up and fax all back at the end of the week or whenever it is convenient for our staff?

The necessary information concerning a discharge date or additional information to complete a concurrent review should be submitted to Conduent by phone or fax as soon as the information is available. This will help to close out certifications with discharge dates and eliminate repeated information on the next day’s report. This will also facilitate the timeliness of concurrent reviews. If multiple areas of the hospital (i.e. psych and acute care) should receive this information, please provide the correct contact information (person’s name and fax number) to Conduent.

Adding all dual eligible (Medicare/Medicaid) participants to the Daily Discharge/Expired Certification report in addition to the discharge information on each patient is quite labor intensive. Is this information required? What is its purpose? Will it affect our payment if we do not add the dual eligibles to the report?

At this point, the information is not required but is requested. This information will help MO HealthNet assist providers in improving patient care during and after discharge. The information does not affect your reimbursement in any way.

Can medical records be sent on a CD?

Yes, a copy of medical records may be sent in a PDF format via a CD to the Inpatient Address in Jefferson City, MO.

My certification request was "closed" or “pended lack of information” due to insufficient information. Do I resubmit the records as a "Request for Reconsideration" or as an "Admission" request?

Any certification request with insufficient information will be denied. A letter will be issued to the provider to let them know this has been done. Submit records as an “Initial Certification”, “Continued Stay”, “Retrospective” or “Admit Date Change” where appropriate. When the records are sent again with the missing information the certification can be considered.

Is there an email address where questions concerning the inpatient utilization review process may be sent?

For Inpatient Utilization review process questions please call UR Assistant line at (800) 766-0686
Opt. 0.

Where will the Inpatient UR Certification Request Form be located?

The form will be located on the following website: Click
on the FORMS link on the black toolbar in the middle of the page. This will bring up a list of forms.