Inpatient urgent/emergent admissions authorization rules 

The Priority Health Utilization Review program uses the following rules to authorize services for observation vs. inpatient admission for contracted hospitals. This applies to members of all products and lines of business.

  • Facilities have 24 hours or the next business day to notify the health plan of an urgent/emergent admission event. Use the Auth Request online automated authorization system to make your request through Clear CoverageSM.
  • Utilization Review staff review authorization requests with clinical documentation using InterQual 2018® medical necessity criteria to issue a coverage decision.

Codes authorized/billable as observation 

Diagnosis code (ICD10) Diagnosis description
Cardiac
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I48.0 Paroxysmal atrial fibrillation
I48.91 Unspecified atrial fibrillation
R07.89 Other chest pain
I11.0 Hypertensive heart disease with heart failure
R55 Syncope and collapse
I16.0 Hypertensive urgency
R07.9  Chest pain, unspecified
Endocrine
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E11.65 Type 2 diabetes mellitus with hyperglycemia 
Pulmonary  
J18.9 Pneumonia, unspecified organism 
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.9 Chronic obstructive pulmonary disease, unspecified 
J45.901 Unspecified asthma with (acute) exacerbation 
Gastrointestinal  
K80.00  Calculus of gallbladder with acute cholecystitis without obstruction
K56.60 Unspecified intestinal obstruction 
K92.2 Gastrointestinal hemorrhage, unspecified
K52.9 Noninfective gastroenteritis and colitis, unspecified
K92.1 Melena
K35.3 Acute appendicitis with localized peritonitis
E86.0 Dehydration
K56.69 Other intestinal obstruction
K81.0 Acute cholecystitis;
A09 Infectious gastroenteritis and colitis, unspecified
D64.9  Anemia, unspecified 
ID  
T81.4Xxa Infection following a procedure, initial encounter
N39.0  Urinary tract infection, site not specified 
L03.115  Cellulitis of right lower limb
L03.116  Cellulitis of left lower limb
L03.114 Cellulitis of left upper limb
L03.113 Cellulitis of right upper limb
GU
N17.9  Acute kidney failure, unspecified
N13.2 Hydronephrosis with renal and ureteral calculous obstruction 
E87.1 Hypo-osmolality and hyponatremia 
Neurology  
I63.9  Cerebral infarction., unspecified 
I63.8 Other cerebral infarction 
G45.9  Transient cerebral ischemic attack, unspecified 
R53.1 Weakness 
G40.909  Epilepsy, unspecified, not intractable, without status epilepticus
G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus  
Miscellaneous  
Z51.89 Encounter for other specified aftercare
Z47.1 Aftercare following joint replacement surgery 
Z47.89  Encounter for other orthopedic aftercare
Z48.89 Encounter for other specified surgical aftercare
I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity 
I82.402 Acute embolism and thrombosis of unspecified deep veins of left lower extremity 
I82.621 Acute embolism and thrombosis of deep veins of right upper extremity 
I82.622 Acute embolism and thrombosis of deep veins of left upper extremity