Question on The Newborns' and Mothers' Health Protection Act of 1996

[metsfan026]

I'm not someone who processes claims, but we help administer a few plans.  The TPA denied the following services, saying that they needed to be pre-authorized.  My question is, with the The Newborns' and Mothers' Health Protection Act of 1996, I know that says that pre-authorization is not needed for the 48 or 96 hour hospital stay in regards to having a baby but do these services also fall under the no need to pre-authorize: 

Thanks in advance!

[SPDkim]

On 11/1/2022 at 10:07 AM, metsfan026 said:

I'm not someone who processes claims, but we help administer a few plans.  The TPA denied the following services, saying that they needed to be pre-authorized.  My question is, with the The Newborns' and Mothers' Health Protection Act of 1996, I know that says that pre-authorization is not needed for the 48 or 96 hour hospital stay in regards to having a baby but do these services also fall under the no need to pre-authorize: 

Thanks in advance!

I could see the private rooms requiring pre-authorization, but don't see why the rest would need pre-auth. And prior auth is never required for emergency room visits, per the No Surprises Act.

[Scott A. Davis]

This depends on Self-Funded or Fully-Insured see the FAQs below:

https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/nmhpa.pdf

For those plans with coverage that is insured by an insurance company or HMO, contact your state insurance department for the most current information on the state laws that pertain to hospital length of stay in connection with childbirth. Also for covered services, see the certificate of coverage and pre-authorization requirements.

 

Can my group health plan require me to get permission (sometimes called prior authorization or precertification based upon medical necessity) for a 48-hour or 96-hour hospital stay?

No. A plan cannot deny you or your newborn child coverage for a 48-hour stay (or 96-hour stay) because the plan claims that you, or your attending provider, have failed to show that the 48-hour stay (or 96-hour stay) is medically necessary. However, plans generally can require you to notify the plan of the pregnancy in advance of an admission in order to use certain providers or facilities or to reduce your out-of-pocket costs.

I hope this points you in the right direction,

[metsfan026]

15 hours ago, Scott A. Davis said:

This depends on Self-Funded or Fully-Insured see the FAQs below:

https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/nmhpa.pdf

For those plans with coverage that is insured by an insurance company or HMO, contact your state insurance department for the most current information on the state laws that pertain to hospital length of stay in connection with childbirth. Also for covered services, see the certificate of coverage and pre-authorization requirements.

 

Can my group health plan require me to get permission (sometimes called prior authorization or precertification based upon medical necessity) for a 48-hour or 96-hour hospital stay?

No. A plan cannot deny you or your newborn child coverage for a 48-hour stay (or 96-hour stay) because the plan claims that you, or your attending provider, have failed to show that the 48-hour stay (or 96-hour stay) is medically necessary. However, plans generally can require you to notify the plan of the pregnancy in advance of an admission in order to use certain providers or facilities or to reduce your out-of-pocket costs.

I hope this points you in the right direction,

It is a self-insured plan.  So, based on this, pre-authorization would not be required correct?