UniCare Health Plan of West Virginia, Inc. (UniCare) does not require prior authorization for treatment of emergency medical conditions. In the event of an emergency, members may access emergency services 24/7.
In the event that the emergency room visit results in the member’s admission to the hospital, providers must contact UniCare the next business day following admission or post-stabilization. UniCare intake staff will verify eligibility and determine benefit coverage.
UniCare is available via fax at 1-855-402-6985 or ICR (via Availity*), 24 hours a day, 7 days a week, to accept emergent admission notification. For full details regarding emergency room claims, emergency care and hospital stays, please refer to the Provider Manual.
* Availity, LLC is an independent company providing administrative support services on behalf of UniCare Health Plan of West Virginia, Inc.
Hospitals must notify the Utilization Management department of inpatient medical admissions within 24 hours of admission or by the next business day. If there is insufficient clinical information to determine medical necessity, the provider is contacted with a request for the clinical information reasonably necessary to make this determination. Evidence-based criteria are used to determine medical necessity and the appropriate level of care.
For full details regarding continued stay review, please refer to the Provider Manual.
UniCare does not reimburse for readmission for a related condition within seven days of discharge from a previous hospital confinement, in accordance with the BMS policy for readmissions. UniCare may require medical records and review readmissions within 30 days of discharge to determine if the member was discharged early. Claims for readmissions within 30 days that are due to early discharge may be denied. This UniCare reimbursement policy is in line with the BMS reimbursement policy.
For the very latest communications from UniCare regarding COVID-19 and other policy updates, please visit the Provider News & Announcements page.