word UNM Health Sciences Center Administrative Policies and by fionan

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									                                                                                       Administrative
                                                                                   Policies and Procedures
                                                                                 Domain:    6-Health Systems
                                                                                   Class:
                                                                                  NIC #:

  University of New Mexico Health Sciences
                                                                                   Index:   Administrative/Operational
                   Center                                                                   HSC, P&P

Policy # 10                                                                      Primary Age Group:    All Ages
     Out-of-County Medically Indigent Financial
                    Assistance                                                       Newborns         Pediatrics   X   Adults   X




POLICY:

          It is the policy of the University of New Mexico Health Sciences Center
           (UNMHSC) Clinical Operations that Out-of-County Indigent (OOCI) Financial
           Assistance is a charity care resource provided by UNMHSC to indigent residents
           of New Mexico counties for the medical care they receive at the UNMHSC
           clinical facilities. (“Charity care” is not a payor source, but only means that
           UNMHSC is allowed by federal laws and regulations to forego pursuit of billing
           and collection for that particular patient.) Patients must apply at the University of
           New Mexico Hospital (UNMH) Business Office for this financial assistance and
           must be able to demonstrate that they are medically indigent under uniform
           criteria adopted by the UNMHSC, in compliance with applicable state and federal
           laws and regulations.

          OOCI Financial Assistance supports only care that is medically necessary as
           determined by UNMHSC Medical Staff in accordance with UNMHSC Medical
           Staff Rules, Policies and Procedures. Generally, OOCI Financial Assistance is
           available for inpatient care, day surgery and ambulatory care that are not available
           in the county of residence of the patient.

          OOCI Financial Assistance is not available to patients who have a payor source,
           such as Medicare, Medicaid, commercial insurance, HMOs, county indigent
           funds, or other third party payors. OOCI is not available to patients who meet
           criteria for Bernalillo County Financial Assistance, as described in that policy.
           Financial assistance for non-United States citizens is subject to the Medical
           Services and Financial Assistance for Non-United States Citizens Policy. As
           explained in that policy, indigent non-United States citizens who are legal aliens


DOMAIN: ___6-Health Systems______________                                                              Policy and Procedure
CLASS: __________________
NIC NUMBER: ____________               TITLE: Out-of-County Medically Indigent                          Page   1
INDEX: HSC Administrative / operational P&P
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           are eligible for OOCI Financial Assistance if they meet the criteria described in
           this policy.

POLICY CROSS REFERENCE:
             Patient Payment Policy
             Bernalillo County Financial Assistance Policy
             Financial Assistance Eligibility Guidelines
              Medical Services and Financial Assistance for Non-United States Citizens
           Policy
             Inter-Hospital and Emergency Department Transfers to UNMHSC Policy
             Admissions/Discharge Policy
             Low Income Uninsured Patient Discount

GENERAL INFORMATION AND DESIRED OUTCOME:

This policy defines the following:

          Which patients are eligible for OOCI Financial Assistance
          Which types of medical services are covered by OOCI Financial Assistance
          What patients must do to become eligible for OOCI Financial Assistance

ELIGIBILITY REQUIREMENTS –
ALL THESE CONDITIONS MUST BE MET:

          Patients must meet indigency criteria set forth in UNMHSC financial guidelines
           established by the UNMH Business Office.
          Patients must be receiving a level of care or services not available in their home
           county.
          Patients must reside in New Mexico for more than 90 days and be U.S. citizens or
           non-U.S. citizens who are legal aliens.
          Patients must have applied for and been denied OOCI funds from their home
           county or must have recently moved to Bernalillo County but not yet qualified for
           Bernalillo County Financial Assistance.

PROCEDURE:

 1. Elective Admissions:

    1.1. Patients residing in counties that do not have acute care hospitals (for example,
         Sandoval, Mora, Valencia and Torrance counties) do not need approval from

DOMAIN: ___6-Health Systems______________                                             Policy and Procedure
CLASS: __________________
NIC NUMBER: ____________               TITLE: Out-of-County Medically Indigent         Page    2
INDEX: HSC Administrative / operational P&P
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           Utilization Review (UR) or equivalent for elective admissions. Patients residing
           in those counties will be reviewed by UR for appropriateness of care and
           tracking.

    1.2. Patients residing in counties with hospitals need approval from UR. Patient
         service representatives should complete a Patient Services Representative Order
         (PSRO) and submit to UR prior to date of admission. If services are available in
         the patient’s home county, the patient will be denied OOCI Financial Assistance
         for the admission. If the patient chooses to proceed with the admission, the
         patient will be classified as self pay and required to make an initial payment
         toward the estimated costs of the admission and care. The patient may request
         OOCI financial assistance from his/her home county. If approved by his/her
         home county for such assistance, the initial payment may be waived.

    1.3. Six-month post-operative follow-up care will be approved for an admission
         qualifying for OOCI Financial Assistance from UNMHSC. This assistance may
         be extended up to one year if the services are related to the original admission
         diagnosis.

 2. Emergency Admissions:

    2.1. If a patient is transported by air ambulance, UR or equivalent will review for
         approval after admission.
    2.2. If the patient is self-transported, UR or equivalent will review for approval after
         admission, except for patients from counties with no acute care hospitals.
    2.3. If the patient is transported by ground ambulance, UR will review after
         admission for approval, except for patients from counties with no acute care
         hospitals.
    2.4. New Mexico residents admitted in an emergency while visiting or driving
         through will be reviewed after admission by the UNMH Business Office for
         eligibility for OOCI Financial Assistance or for financial classification as self
         pay if they have no third-party payor.

 3. Outpatient:

    3.1. Primary care physician visits are not covered by OOCI Financial Assistance.
         Patients will be classified as "self pay" for those visits.
    3.2. Specialty visits may be covered under the following circumstances:
          3.2.1.If no appropriate specialist is practicing in the patient’s home county, and
          3.2.2 The patient is referred to a UNMHSC specialist by a primary care
                  physician.
    3.3. A Patient Services Representative (PSR) must check for the following:
        3.3.1. An appointment in a specialty clinic (see attached list).
        3.3.2. Whether that type of specialist is practicing in the patient’s home county.


DOMAIN: ___6-Health Systems______________                                            Policy and Procedure
CLASS: __________________
NIC NUMBER: ____________               TITLE: Out-of-County Medically Indigent        Page   3
INDEX: HSC Administrative / operational P&P
01/27/00
    3.4. If no specialist is practicing in the patient’s home county, the PSR will approve
         the specialty visit.
    3.5. If there is a specialist practicing in the patient’s home county, the PSR will deny
         OOCI Financial Assistance for the specialty visit.
    3.6. If the PSR is unsure, he/she will contact UR.
    3.7. Emergency Room (ER) / Urgent Care Center (UCC) Visits
        3.7.1. ER/UCC visits may be approved for OOCI Financial Assistance, if:
             3.7.1.1.     Patient traveling/visiting in Albuquerque and becomes ill or hurt.
             3.7.1.2.     Any trauma or life threatening emergencies.
             3.7.1.3.     Any patients flown to Albuquerque by air ambulance.
             3.7.1.4.     Any ER visits over $200.
        3.7.2. Visits to the ER for routine care are not covered.
        3.7.3. There is no automatic approval for follow-up visits.
        3.7.4. The UNMH Business office will approve only the ER visit. If the patient
                 is referred to a specialist through the ER/UCC then the PSR will follow
                 guidelines for approval of any specialty visits.




DOMAIN: ___6-Health Systems______________                                           Policy and Procedure
CLASS: __________________
NIC NUMBER: ____________               TITLE: Out-of-County Medically Indigent       Page   4
INDEX: HSC Administrative / operational P&P
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KEY DOCUMENTATION:

NOTE: Denial letters from the patient’s home county will be identified with patients’
accounts and retained for reporting purposes within the UR department.


AGE OR DEVELOPMENTAL VARIATIONS




UNIT OR AREA SPECIFICS




DOMAIN: ___6-Health Systems______________                                        Policy and Procedure
CLASS: __________________
NIC NUMBER: ____________               TITLE: Out-of-County Medically Indigent    Page   5
INDEX: HSC Administrative / operational P&P
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/s/ Stephen McKernan                                               10/11/2004
Stephen McKernan, Associate Vice President for Clinical Operations           Date


/s/ Paul B. Roth, M.D.                                                           10 /11/2004
Paul Roth, M.D., Associate Vice President for Clinical Affairs                             Date




Development Date:             November, 1999, October, 2004
Developed by:                 OOCI Process Review Team
Revised Date:                 6/2000, 8/2004, 10/2004
Reviewed By:                  Kitty Fleschute, Area Director
                              Patient Financial Services,
                              Stephany Wilson, Senior Associate
                              University Counsel
Approved By:                  See Above
Approved Date:                8/11/2004, 10/04


Out-of-County Medically Indigent Financial Assistance 8-04.doc
Replaces “Out of County Medically Indigent”
Posted 8/20/04 Catherine Joy, Clinical Operations Policy Coordinator




DOMAIN: ___6-Health Systems______________                                                Policy and Procedure
CLASS: __________________
NIC NUMBER: ____________               TITLE: Out-of-County Medically Indigent            Page   6
INDEX: HSC Administrative / operational P&P
01/27/00

								
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