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November 4, 2010 Re: Guidelines for Observation Services Dear Participating Provider: Coventry Health Care of DE (CHCDE)/Diamond Plan of Coventry Health Care (DP) would like to take this opportunity to provide you with information on our guidelines for observation services. CHCDE/DP utilizes InterQual criteria to assist in determining the medical necessity for observation stay services and all inpatient admissions. We define observation services as a stay requiring less than forty-eight (48) hours of care where stabilization and discharge can reasonably be expected within that time frame. Some examples of medical conditions that may meet observation level of care are: Chest Pain Allergic Reactions Urinary Retention Post Trauma/Accidents Hypertension Alcohol/Drug Intoxication Vomiting/Dehydration Post-operative complication (outpatient surgery) Abdominal Pain Altered Mental Status Back Pain Bleeding Kidney Stones Seizure Diarrhea Asthma Anemia Pneumonia Headache Syncope T.I.A. DVT

The following are not considered for observation level of care: Routine stays following late surgery Normal post-operative recovery following surgery Observation prior to outpatient surgery Diagnostic Testing Staying past 48 hours Convenience

If a member is in observation status greater than forty-eight hours or is admitted to inpatient after being observed, you must notify our Prior Authorization Department at 800-727-9951. We greatly appreciate your continued partnership with CHCDE/DP in ensuring our members receive the highest quality care. Sincerely,

Mark Noveck, MD Medical Director Coventry Health Care of Delaware


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Observation Notice.doc