Short Term Inpatient Hospital Stay Policy Notice

Date: 01/14/25

Effective February 12, 2025, Sunflower will be adhering to the following Inpatient Short Stay clinical policy.  Sunflower is committed to working with providers to ensure members are at the appropriate level of care.  Inpatient stays of two days or less will be subject to the policy. 

The Sunflower Health Plan Short Inpatient Hospital Stay Policy CP.MP.182 addresses medical necessity criteria for day one and day two of an inpatient hospital stay, excluding behavioral health and obstetrical delivery admissions.  As indicated in the policy, observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment prior to deciding whether the patient will require further treatment at an inpatient level of care. 

Inpatient claims denied under this policy are deemed to meet observation level of care based on the criteria presented at the time of admission.  If you agree with the determination, a corrected claim can be submitted for observation level of care with the appropriate revenue code and HCPCS combination.

If you disagree with this determination, refer to our provider manual for information on how to file a reconsideration or appeal. Our provider manual is available on our website and can be referenced for additional details.

Refer to the KMAP Hospital Provider Manual for observation room requirements

Peer-to-Peer Process

As a reminder, providers may request a peer-to-peer review of any inpatient admission denied under the Short Inpatient Hospital Stay Policy when prior authorization has been requested and the member is in the facility. This allows a concurrent review of the inpatient admit and all applicable criteria, prior to submission of the claim. Providers can request a peer-to-peer review by calling the number on their decision notice.

If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative or call Customer Service at 1-877-644-4623.