For Providers: Authorizations–Inpatient Utilization Review

Starting February 4, 2019, Care Wisconsin will provide centralized processing of Inpatient Authorizations. The information below provides a summary of inpatient utilization review at Care Wisconsin. The Reference Guide document will be stored in the Provider’s Resource Library.

  • Let Us Know – Prompt notification of an admission is important. Please notify us within one business day of all urgent or emergent admissions using the Inpatient Admission Prior Authorization Form for medical admissions or the Inpatient Behavioral Health Treatment and Services Prior Authorization Form for behavioral health admissions. Fax the form and
    supporting clinical documentation to 608-210-4050.
  • Initial Review – Once we have been notified of the admission, the member’s case will be assigned to a Utilization Review RN who will process for medical necessity using InterQual and other evidenced-based clinical standards of care.
  • Care Management – The Care Wisconsin Care Team staff is also notified of the admission and is available to discuss the member’s discharge needs.
  • Certification – We will issue written certification of all stays that meet medical necessity within one business day of receiving pertinent clinical documentation.
  • Concurrent Review – Review is completed daily for Observation stays and every two days for all other Inpatient stays. For prompt authorization, please send updated clinical information to support the continued stay. Clinical documentation should be faxed to 608-210-4050.
  • Ongoing Communication – Care Wisconsin will continue to issue certification letters for additional days meeting medical necessity.
  • Secondary Review – If at any time a stay is not meeting medical necessity, it will be reviewed by Care Wisconsin’s Medical Director.
    • Notification of Decision – Care Wisconsin will notify the servicing provider within one business day of making a decision to deny a stay deemed not medically necessary. The member, requesting provider, and servicing provider will also be issued written notification within 24 hours of making the decision to deny as not medically necessary.