Partners works with a number of hospitals to provide inpatient services for enrollees. This section contains information for hospital providers.
- Hospitals interested in contracting with Partners as in-network providers should complete the Hospital Data Form
- Register additional licensed practitioners with Partners Hospital-Based Clinician Registration Worksheet
Partners requires prior authorization for inpatient admissions. Hospitals seeking to admit a Partners’ enrollee for inpatient psychiatric treatment should call the UM Hospital Admissions Team at 704-842-6434. Staff is available 9 to 7 p.m., seven days a week.
Details regarding authorization can be located in the Partners’ Provider Operations Manual and the Hospital Behavioral Health Facility Instructions Manual.
░ Quick Links: |
| ► Emergency Department Reimbursement Form ► Special Project Enrollment Form |
Inpatient Document/Form Information Grid
| ► Hospital Behavioral Health and Acute Care Facility Instructions ◄ |
|---|
| Document Information | Frequency of Submission | Forms and Document Links | How to Submit to Partners |
|---|---|---|---|
| Out of Network Hospital Single Client Inpatient Application/ Agreement
This three-pages document serves as the contractual agreement for the inpatient services. |
Each admission/episode of care per enrollee | Out of Network Hospital Consumer Specific Agreement | Send via Secure email to providers@partnersbhm.org |
| Inpatient Review Form | At admission and per benefit plan limits until discharged | Inpatient Review Form | Send via Secure email to providers@partnersbhm.org
OR Information can be given via telephone interview with UM reviewers at 704-842-6434 7 days per week 8 a.m.-7 p.m. |
| Manual Service Authorization Request (SAR) | At admission and per benefit plan limits until discharge | Manual Service Authorization Form | Send via Secure email to providers@partnersbhm.org
OR Information can be given via telephone interview with UM reviewers at 704-842-6434 7 days per week 8 a.m.-7 p.m. |
| Copy of Certificate of insurance for General & professional liability, automobile coverage as applicable, workers comp | Each admission/ episode of care per recipient. Should cover the dates of service of the admission | N/A | Send via Secure email to providers@partnersbhm.org |
| Hospital-Based Clinician Registration Worksheet | Each Admission/episode of care per recipient if attending physician services are billed as part of inpatient services by hospital | Hospital-Based Clinician Registration Worksheet | Send via Secure email to providers@partnersbhm.org |
| Trading Partners BHM Agreement – Used only if filing claims using HIPAA compliant transactions. | Submitted one (1) time and kept on file unless there are changes. If already submitted for other services such as Emergency Department services, does not have to be submitted again unless there are changes. | Trading Partner Agreement
OR Will be mailed by Finance staff with fully executed out of network agreement for the facility’s first agreement submitted |
Send via Secure email to providers@partnersbhm.org
OR Mail directly to: |
| W-9 | Each admission/episode of care | N/A |