will apply to all services performed on or after the above revision date which
will become the new effective date.
services referred to in this policy that were performed before the revision
date, contact customer service for the rules that would apply.
Acquired Conditions (HACs):
secondary conditions that are not present at the time of admission but occur
during the hospital stay. In many cases HACs are commonly seen complications
that, unfortunately, cannot be prevented even with the best of care.
Of the many
possible HACs, there is a subset
which could reasonably have been
prevented through application of widely accepted, evidence-based guidelines or
will identify these events and apply a no payment policy for preventable HACs at
in network hospitals (no additional payment beyond what is routinely paid for
the primary admitting diagnosis or procedure). This will bring QualChoice policy
more closely in line with CMS (Medicare/Medicaid) policy regarding preventable
currently recognizes 14 major categories of preventable HACs:
HAC 01 – Foreign body retained following surgery
HAC 02 – Air embolism
HAC 03 – Blood incompatibility
HAC 04 – Stage III and IV pressure ulcers
HAC 05 – Falls and trauma
HAC 06 – Catheter-associated UTI (CAUTI)
HAC 07 – Vascular catheter-associated infection
HAC 08 – Surgical site infection (SSI): Mediastinitis following CABG
HAC 09 – Manifestations of poor glycemic control
HAC 10 – Deep vein thrombosis (DVT) or pulmonary embolism (PE) with total
HAC 11 – Surgical site infection (SSI): following bariatric surgery
HAC 12 – Surgical site infection (SSI): following certain orthopedic procedures
shoulder or elbow
HAC 13 – Surgical site infection (SSI): following cardiac implantable electronic
HAC 14 – Iatrogenic pneumothorax with venous catheterization
The above list is subject to change over time and is not all inclusive. Some
HACs are identified simply by diagnosis codes not present on admission while
others may only be identified when specific procedure codes are associated with
specific diagnosis codes.
Preventable HACs Identified During Concurrent Review
During the course of a hospitalization, hospitals may ask for prior approval of
additional days beyond what was initially expected/approved. This process is
called concurrent review. If during the process of concurrent review, it
becomes apparent there are preventable HACs involved, prior approval of
additional days cannot be granted because there is no ability to accurately
determine which additional days are a result of preventable HACs (hospital
responsibility) and which are not. In these situations, the only fair and
accurate way to determine medically necessary hospital days and services is
through a retrospective review of the medical records and itemized charges.
Despite lack of concurrent approval of for additional days, the hospital still
has a clinical, ethical and legal responsibility to continue providing necessary
Preventable HACs Identified During Retrospective Review
While preventable HACs can be identified during concurrent review, they may also
be identified retrospectively at the time of claim submission. If a submitted
claim is suggestive of preventable HACs, QualChoice will not process the claim
until medical records and itemized statements are provided for review. This
review will determine which services were medically necessary services and not a
result of preventable HACs.
or services that are related to preventable HACs will not be approved.
Hospitals must assume responsibility for preventable HACs and cannot pass this
responsibility on to insurers or to patients.