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Multi-Vehicle Collision — Bilateral Femur Fractures
34-year-old male, Molina Healthcare of Ohio (Medicaid MCO)
Total
$142,800
Reimbursed
$78,400
Denials
None
Construction Fall — Spinal Cord Injury (Incomplete)
47-year-old male, UnitedHealthcare Commercial PPO
Total
$387,200
Reimbursed
$224,600
Denials
1 denial (ultralight wheelchair)
Pedestrian Struck by Vehicle — TBI + Orthopedic Injuries
62-year-old female, Uninsured → Medicaid presumptive eligibility
Total
$524,600
Reimbursed
$265,400
Denials
1 denial (IRF admission)
EMS arrives 8 min post-collision. GCS 14, bilateral femur deformity, tachycardic (HR 118). Traction splints applied. Ohio trauma triage protocol: ISS criteria met → Level I trauma center direct transport. 22-min ground transport.
FHIR R4 Resources Updated
Payer Actions
No payer involvement at this stage — emergency stabilization under EMTALA
Eligibility not yet verified; trauma activation proceeds regardless of coverage status
Applicable Policies & Regulations
EMTALA (42 USC §1395dd): Mandates medical screening exam and stabilization regardless of insurance status or ability to pay
Ohio trauma triage protocol (OAC 4765-14): Field triage criteria for direct transport to verified trauma center
Level I trauma activation. Primary survey: airway intact, bilateral femur fractures confirmed. FAST negative for free fluid. CT head/c-spine negative. CT pelvis: no acetabular involvement. Labs: Hgb 10.2, lactate 3.1. Trauma activation fee billed (S9083). Eligibility verification initiated via Availity 270/271.
FHIR R4 Resources Updated
Payer Actions
Availity 270/271: Molina Medicaid coverage confirmed active — no copay for emergency services
Molina notified of trauma admission per contractual 24-hour notification requirement
Third-party liability (TPL) flag initiated — MVC may involve auto insurance primary payer
Applicable Policies & Regulations
Molina Ohio Provider Manual §4.3: Emergency services do not require prior authorization
Ohio Medicaid (OAC 5160-2-07.17): Retrospective review authorized for ED admissions; concurrent review begins at day 3
Molina TPL coordination: Auto liability/PIP coverage investigated as primary payer per 42 CFR §433.138
OR case: bilateral closed reduction and IM nailing under general anesthesia. 3.2 hours operative time. EBL 800 mL, 2 units PRBCs transfused. Intraoperative fluoroscopy confirms acceptable alignment. Post-op to SICU for monitoring.
FHIR R4 Resources Updated
Payer Actions
No PA required for emergency surgical intervention — Molina emergency services exemption
DRG assignment: MS-DRG 480 (Hip & femur procedures, MCC) — estimated Molina payment: $18,200
Applicable Policies & Regulations
Molina Ohio: Emergency surgery does not require prior authorization; retrospective clinical review will validate medical necessity
Ohio Medicaid DRG payment methodology (OAC 5160-2-65): Hospital paid per DRG with outlier threshold at 3x geometric mean LOS
SICU days 1–2: hemodynamic monitoring, DVT prophylaxis, pain management (PCA morphine → oral). Step-down to floor day 3. PT initiated day 2: bed mobility, transfers. CDI captures ISS 22, bilateral fractures, blood loss anemia. Molina concurrent review initiated day 3.
FHIR R4 Resources Updated
Payer Actions
Molina UM: Concurrent review initiated day 3 per Ohio Medicaid rules; clinical update submitted via Availity Payer Space
Molina approves continued stay through day 5 based on InterQual Acute Care criteria (bilateral fracture + ICU step-down)
CDI documentation: ISS 22, MCC-qualifying conditions captured → DRG 480 with MCC holds
Applicable Policies & Regulations
OAC 5160-2-07.17: Concurrent review required for trauma stays >3 days; Molina reviews every 48 hrs
Molina UM Policy: InterQual Acute Care criteria for continued stay; clinical updates required every 48 hrs via Availity
CMS-0057-F (effective Jan 2026): Molina must provide decision within 72 hrs for urgent concurrent review requests
FIM score: 62/126 (moderate dependence). Non-weight-bearing bilateral lower extremities. Lives alone, 2nd floor walk-up — home discharge not safe. Case management initiates SNF referral. DME: wheelchair, walker, shower chair. PT recommends 3–4 weeks SNF-level rehab. PA submitted for SNF and DME via Availity.
FHIR R4 Resources Updated
Payer Actions
SNF PA submitted via Availity X12 278 to Molina — approved for 21 days (of 100 benefit period max)
DME PA (wheelchair + walker + shower chair) submitted via Molina Payer Space — approved within 48 hrs
Molina transition-of-care notification triggered to SNF and PCP
Applicable Policies & Regulations
Ohio Medicaid SNF: No 3-day hospital stay requirement (unlike Medicare); direct SNF admission allowed for Medicaid-only patients
Molina SNF PA Policy: Initial approval up to 21 days; extensions via P2P with Molina medical director if skilled need documented
Molina DME PA: Required for items >$500; LCD-aligned documentation including functional limitation and medical necessity statement
CMS-0057-F: Standard PA decision within 7 calendar days; Molina compliant as of Jan 2026
Admitted to SNF day 7. PT 5x/week: progressive weight-bearing per orthopedic protocol. OT 3x/week: ADL retraining, transfer technique. Weekly FIM tracking: 62 → 74 → 88. Surgical follow-up at 2 weeks: x-rays show progressing callus formation. Molina extends SNF authorization at day 21 review.
FHIR R4 Resources Updated
Payer Actions
Molina concurrent review at day 21: FIM progress documented (62→74); skilled need criteria met for extension
SNF extension approved to day 35 via P2P with Molina medical director
SNF per diem claims submitted weekly via Availity 837I; Molina processes within 30 days
Applicable Policies & Regulations
Molina SNF Coverage: Up to 100 days per benefit period; extensions require documented skilled need and measurable functional progress
Molina P2P Process: Attending can request physician-to-physician review within 48 hrs of any denial or pending decision
Ohio Medicaid SNF rate: Per diem based on Resource Utilization Group (RUG) classification; higher acuity = higher rate
Discharged from SNF day 35. FIM 94/126. Partial weight-bearing bilateral. Outpatient PT 3x/week. 6-week follow-up: full weight-bearing authorized. 12-week follow-up: return to light duty work. Final FIM 118/126. Molina closes case.
FHIR R4 Resources Updated
Payer Actions
Outpatient PT: Molina covers 60 visits/year under Medicaid benefit; no PA required for first 20 visits
Final claim reconciliation: All inpatient, SNF, and outpatient claims adjudicated; no denials in this scenario
TPL investigation closed: Auto insurance PIP coverage confirmed primary for $10,000; Molina secondary for remainder
Applicable Policies & Regulations
Molina Ohio outpatient rehab: 60 visits/year covered; PA required after visit 20 per Molina UM policy
Ohio Medicaid TPL recovery (OAC 5160-1-09): Molina entitled to recover from auto PIP/liability as primary payer
42 CFR §433.138: Medicaid as payer of last resort — TPL identification and recovery mandatory
Total Charges
$142,800
Reimbursement
$68,400 (Molina) + $10,000 (auto PIP) = $78,400
Denials / Appeals
None — concurrent review compliance and documentation prevented denials
Co-worker calls 911. EMS arrives 6 min. GCS 15, severe back pain, diminished sensation bilateral lower extremities, unable to move legs. Full spinal immobilization. Ohio trauma triage: mechanism + neuro deficit → air medical activated. 18-min helicopter transport to Level I center.
FHIR R4 Resources Updated
Payer Actions
No payer involvement — EMTALA applies
Workers' compensation investigation initiated by employer; may become primary payer
Applicable Policies & Regulations
EMTALA: Stabilization mandate regardless of insurance
Ohio Workers' Compensation (BWC): Workplace injury triggers WC investigation; WC would be primary payer if claim accepted
UHC Commercial: Emergency services covered at in-network rate regardless of facility network status (prudent layperson standard)
Full trauma activation. Primary survey: airway intact, neuro exam confirms ASIA C incomplete SCI at T11. MRI thoracolumbar: burst fracture T12 with posterior ligamentous complex injury, cord compression with signal change. CT chest/abdomen: no other injuries. Eligibility check via Availity: UHC Commercial PPO confirmed.
FHIR R4 Resources Updated
Payer Actions
Availity 270/271: UHC PPO active, in-network verified, deductible $1,500 (met: $400 YTD), OOP max $6,000
UHC notification: Trauma admission reported within 24 hrs per contract requirement
Workers' comp status: Pending BWC investigation; UHC processes as primary pending WC determination
Applicable Policies & Regulations
UHC 2026 Administrative Guide: Emergency admissions require notification within 24 hrs; concurrent review begins day 2 for trauma
UHC PPO: Prudent layperson standard for emergency — in-network cost-sharing regardless of facility
Ohio BWC: 14-day investigation period for workplace injury claims; if accepted, WC retroactively becomes primary
Emergent posterior approach: laminectomy T12, decompression of spinal cord, posterior instrumented fusion T10-L2 with pedicle screws. 5.8 hours operative time. EBL 1,200 mL, 3 units PRBCs + 2 units FFP. Intraoperative neuromonitoring maintained. Post-op to Neuro ICU.
FHIR R4 Resources Updated
Payer Actions
Emergency surgery: No PA required per UHC emergency exception
DRG 453: High-weight DRG; UHC case-rate payment estimated at $62,000 (in-network contracted rate)
Implant costs: Pedicle screw system ~$22,000; included in DRG payment unless outlier threshold met
Applicable Policies & Regulations
UHC Medical Policy: Emergency spinal surgery exempt from PA; retrospective review for medical necessity within 30 days
UHC 2026: PA removed for select categories but spinal fusion still requires retrospective review for appropriateness
NCCI PTP edits: 22612 + 63047 allowed on same date with modifier 59 (separate procedure at different level)
Neuro ICU days 1–4: neurogenic shock management, vasopressor support, DVT prophylaxis (IVC filter placed). Step-down day 5. Rehab medicine consult day 2: ASIA C confirmed, bladder management (intermittent catheterization program). PT/OT intensive: wheelchair mobility, transfer training, UE strengthening. CDI: ISS 29, SCI, neurogenic shock, transfusion → MCC qualifiers documented.
FHIR R4 Resources Updated
Payer Actions
UHC concurrent review (via Optum PA integration): Approved continued acute stay through day 12
UHC criteria: InterQual SCI criteria met — motor incomplete, neurogenic bladder, functional dependency
IRF PA submitted via Availity X12 278: UHC approves 21-day IRF admission (SCI-specific program)
UHC peer-to-peer not required — criteria clearly met per InterQual
Applicable Policies & Regulations
UHC Optum UM: SCI patients require concurrent review every 3 days during acute phase; documentation must address why lower LOC insufficient
CMS IRF criteria (per UHC adoption): Patient must require 2+ therapy disciplines, tolerate 3 hrs/day, benefit from interdisciplinary team, require physician supervision
CMS-0057-F: UHC PA decision for IRF within 7 calendar days (standard) — decision returned in 4 days
Transferred to SCI-specialized IRF. 3 hrs/day minimum therapy. PT: wheelchair propulsion, standing frame, gait training with bilateral KAFOs (return of some motor function). OT: ADLs, self-catheterization training. Psych: adjustment to disability counseling. FIM: 42 → 68 → 86 across 3 weeks. UHC extends to day 30.
FHIR R4 Resources Updated
Payer Actions
UHC concurrent review at day 21: Motor recovery documented (ASIA C → improving, some voluntary movement below T12)
UHC extends IRF to day 30 — motor recovery trajectory supports continued intensive rehabilitation
IRF per diem claims processed weekly via Availity; UHC contracted rate ~$1,800/day
Workers' comp claim DENIED by Ohio BWC (employer safety protocol violation contested) — UHC remains primary
Applicable Policies & Regulations
UHC IRF Policy: SCI patients eligible for extended IRF stay (up to 60 days) with documented motor recovery and FIM improvement ≥2 points/week
CMS IRF-PAI (Patient Assessment Instrument): CMG assignment based on impairment category, FIM motor score, and comorbidity tier
Ohio BWC Appeal: Employer can appeal denied WC claim; 21-day appeal period. If overturned, WC retroactively primary and UHC seeks reimbursement
FIM 94 at IRF discharge. Motor recovery: ASIA D (motor functional). Ambulates with bilateral KAFOs + forearm crutches for short distances; primary wheelchair user for community mobility. DME evaluation: custom ultralight wheelchair ($4,200), hospital bed, shower chair, forearm crutches. Home modification assessment: ramp, grab bars, accessible bathroom. Outpatient rehab plan: PT 3x/week, OT 2x/week.
FHIR R4 Resources Updated
Payer Actions
UHC DME PA via Availity: Hospital bed, shower chair, forearm crutches APPROVED
UHC DME PA: Custom ultralight wheelchair DENIED — UHC policy covers standard wheelchair (K0001) for SCI; ultralight (K0005) requires additional functional mobility justification
Provider initiates appeal: Submits ATP (assistive technology professional) evaluation documenting patient-specific need for ultralight (weight, propulsion efficiency, community mobility)
Patient responsibility: $1,100 remaining deductible + 20% coinsurance on all approved services → estimated OOP to date: $5,400
Applicable Policies & Regulations
UHC Medical Policy #2024T0567U: Ultralight wheelchair coverage requires ATP evaluation documenting specific functional advantages over standard chair
UHC DME Appeal Process: Internal appeal within 180 days; if denied, external IRO review under ERISA § 503 and ACA § 2719
ACA prudent layperson + external review: ERISA plans subject to independent external review — IRO decision is binding on UHC
UHC 2026: Patient OOP max $6,000 individual; patient approaching limit — additional covered services at 100% after OOP met
Outpatient PT/OT: progressive gait training, community mobility, return to function. DME appeal: UHC internal appeal upheld denial; provider files external IRO review. IRO overturns denial — ultralight wheelchair approved. Vocational rehab: Ohio Opportunities for Ohioans with Disabilities (OOD) engaged for return-to-work planning. 6-month follow-up: ambulating with single forearm crutch, wheelchair for long distances. Return to modified duty work.
FHIR R4 Resources Updated
Payer Actions
UHC internal appeal: Denied (upheld original decision); 30-day turnaround
External IRO review: Overturns UHC — ultralight wheelchair is medically necessary for SCI patient community mobility. Binding decision.
UHC processes ultralight wheelchair claim at contracted rate; patient at OOP max → $0 additional cost
Total UHC outpatient PT/OT: 48 visits approved (no PA required for first 20; PA approved for visits 21–48)
Applicable Policies & Regulations
ERISA § 503 + 29 CFR § 2560.503-1: Full and fair review of denied claims; external review for adverse benefit determinations
ACA § 2719 (External Review): Independent Review Organization decision is binding on ERISA plan
UHC 2026 Administrative Guide: After OOP maximum reached, UHC covers at 100% for remainder of benefit year
Ohio OOD (vocational rehab): State-funded return-to-work services for individuals with significant disabilities; no insurance billing
Total Charges
$387,200
Reimbursement
$224,600 (UHC) + $0 (WC denied) = $224,600
Denials / Appeals
1 denial (ultralight wheelchair) — overturned via external IRO review
Multiple bystanders call 911. EMS arrives 5 min. GCS 8 (E2V2M4), anisocoric pupils, open tibia fracture right leg, facial lacerations, pelvic instability. Rapid sequence intubation in field. Pelvic binder applied. Air medical: 14-min helicopter to Level I center.
FHIR R4 Resources Updated
Payer Actions
No insurance identified — EMTALA mandates full stabilization
Hospital financial counselor notified of uninsured trauma admission
Applicable Policies & Regulations
EMTALA: Full stabilization regardless of insurance status
Ohio Hospital Charity Care (ORC §3701.83): Hospitals with >$1M gross revenue must maintain charity care policy; patient may qualify
Ohio Medicaid presumptive eligibility: Hospital can make presumptive determination for hospitalized patients meeting income criteria
Full trauma activation. GCS 8 on arrival. CT head: bifrontal contusions, small SDH, no midline shift — neurosurgery: conservative management with ICP monitoring. CT chest/abdomen: bilateral rib fractures (3–6 left, 4–7 right), grade II splenic laceration (non-operative). CT pelvis: bilateral pubic rami fractures (stable). Right leg: grade IIIA open tibia fracture. Massive transfusion protocol activated: 6 PRBCs, 4 FFP, 1 platelets. Financial counselor begins Medicaid application.
FHIR R4 Resources Updated
Payer Actions
No active coverage — all services provided under EMTALA obligation
Hospital financial counselor initiates Ohio Medicaid presumptive eligibility (PE) application at bedside
Automobile liability investigation: Police report requested; driver's auto insurance identified (GEICO) — potential TPL
Applicable Policies & Regulations
Ohio Medicaid Presumptive Eligibility (OAC 5160:1-2-01.1): Qualified hospitals can grant temporary Medicaid effective immediately, covering hospital services while full application processes
Ohio Medicaid PE income limit: 138% FPL ($20,783/year for individual in 2026); patient's income must be verified
GEICO auto liability: Ohio mandatory minimum $25,000 per person bodily injury liability; may cover medical expenses if driver at fault
Trauma ICU: ICP bolt placed, ICP stable (12–18 mmHg), no surgical intervention needed for TBI. Day 1 OR: right open tibia I&D, external fixation placement (definitive fixation deferred). Pelvic fractures: non-operative, weight-bearing as tolerated. Day 3: GCS improves to 12 (E3V4M5), extubated. Financial counselor: Medicaid PE APPROVED — coverage effective day 0 retroactively.
FHIR R4 Resources Updated
Payer Actions
Medicaid PE approved day 3: Coverage retroactive to day 0 (date of admission)
All prior charges converted from self-pay to Medicaid FFS — billed via Ohio MITS system
Ohio Medicaid FFS: No PA required for emergency and acute inpatient services during PE period
Applicable Policies & Regulations
OAC 5160:1-2-01.1: PE coverage for inpatient hospital services; covers all medically necessary inpatient care during PE period (up to 60 days or until full determination)
Ohio Medicaid FFS: Retrospective review for inpatient admissions; no prospective PA required for emergency admissions
Ohio MITS (Medicaid Information Technology System): Claims submitted via MITS portal or Availity for FFS Medicaid
Days 3–7: TBI recovery — GCS improves to 14, mild cognitive deficits (attention, short-term memory). Day 8 OR: External fixator converted to IM nail for tibia fracture. PT/OT intensive: mobility, cognitive exercises, ADL retraining. Day 14: Full Medicaid application submitted. Day 18: Full Medicaid APPROVED — assigned to CareSource MCO. CDI: ISS 34, polytrauma, TBI + open fracture + splenic injury → MS-DRG 955 (craniotomy for trauma with MCC).
FHIR R4 Resources Updated
Payer Actions
Full Medicaid approved day 18: CareSource assigned as MCO — assumes responsibility from Ohio Medicaid FFS
CareSource: Retroactive to PE start date; all FFS claims transitioned to CareSource for payment
CareSource concurrent review initiated: Approves continued stay through day 22 based on TBI recovery + definitive fixation recovery
CareSource case manager assigned: Coordinates discharge planning, post-acute placement, SDoH assessment
Applicable Policies & Regulations
Ohio Medicaid MCO assignment: Within 30 days of full Medicaid approval, member auto-assigned to MCO if no choice made; CareSource assigned based on county enrollment
CareSource UM Policy: Adopts Ohio Medicaid UM rules; concurrent review per OAC 5160-2-07.17; TBI + polytrauma qualifies for extended acute stay
CareSource transition-of-care policy: New members in active course of treatment — existing providers honored for 90 days regardless of network status
FIM 52/126. Moderate cognitive deficits + bilateral lower extremity injuries = significant functional dependency. Rehab medicine recommends IRF with TBI program. CareSource PA submitted for IRF. DENIED — CareSource determines SNF appropriate based on cognitive status limiting participation in 3 hrs/day therapy. Provider appeals: neuropsych testing shows patient can participate in intensive therapy with cueing. Appeal P2P: CareSource overturns — IRF approved for 21 days.
FHIR R4 Resources Updated
Payer Actions
CareSource initial PA: IRF DENIED — cognitive testing needed to demonstrate therapy participation capacity
Provider submits neuropsych evaluation + rehabilitation potential statement via CareSource Availity Payer Space
P2P appeal with CareSource medical director: OVERTURNED within 48 hrs — IRF approved for 21 days
DME PA: Standard wheelchair + oxygen concentrator approved; hospital bed approved for home discharge post-IRF
Applicable Policies & Regulations
CareSource IRF PA Policy: Requires documentation of ability to participate in ≥3 hrs/day intensive therapy; cognitive status is a common basis for IRF denial in TBI patients
CMS IRF admission criteria (adopted by CareSource): Requires physician supervision, interdisciplinary team, 2+ therapy disciplines, 3 hr/day tolerance
CareSource P2P Process: Physician-to-physician review available within 48 hrs of any denial; expedited review for inpatients
CMS-0057-F: CareSource must provide PA denial reason codes specific enough for meaningful appeal (effective Jan 2026)
IRF TBI program: 3.5 hrs/day therapy with cognitive cueing supports. PT: gait training with walker (tibia healing), balance, endurance. OT: cognitive rehab (attention training, memory strategies, executive function), ADLs. SLP: word-finding, written communication. Neuropsych: weekly cognitive assessment. FIM: 52 → 64 → 78 → 92. Cognitive improvements: RBANS 72 → 84. CareSource extends to day 28.
FHIR R4 Resources Updated
Payer Actions
CareSource concurrent review at day 14: Cognitive + functional improvement documented; extended to day 21
CareSource review at day 21: FIM 78, RBANS 78 → continued gains; extended to day 28
CareSource closes IRF authorization at day 28: FIM 92, cognitive scores approaching functional independence; transition to outpatient
IRF per diem claims submitted weekly via Availity; CareSource rate ~$1,400/day (Medicaid rate)
Applicable Policies & Regulations
CareSource IRF extension: Requires documented FIM improvement ≥2 points/week and ongoing need for interdisciplinary team
Ohio Medicaid IRF: No explicit day limit but CareSource UM reviews weekly and requires active skilled need
CMS IRF-PAI: TBI case-mix group (CMG) assignment based on motor FIM, cognitive FIM, and age; higher CMG = higher payment
Discharged home with home health aide (4 hrs/day × 4 weeks), then outpatient PT/OT/SLP. 3-month follow-up: ambulating with single-point cane, mild persistent memory deficits but independent in all ADLs. 6-month: FIM 112/126, full community independence. GEICO auto liability settlement: $25,000 (policy limit) paid to Ohio Medicaid for TPL recovery.
FHIR R4 Resources Updated
Payer Actions
CareSource home health: Approved 4 hrs/day aide × 28 days; PT/OT/SLP home visits 2x/week × 4 weeks
Transition to outpatient: CareSource covers 60 outpatient rehab visits/year; no PA for first 20
GEICO TPL settlement: $25,000 (Ohio mandatory minimum BI limit) recovered by Ohio Medicaid AG office
Total cost allocation: Ohio Medicaid FFS (PE period charges): $42,000; CareSource (post-MCO assignment): $198,400; GEICO TPL: $25,000
Applicable Policies & Regulations
Ohio Medicaid TPL recovery (OAC 5160-1-09): Attorney General's office pursues TPL recovery from liable auto insurance
42 CFR §433.138: Medicaid payer of last resort; GEICO liability coverage is primary payer for accident-related services
CareSource home health: PA required for aide hours >4 hrs/day or >30 days; skilled nursing/therapy visits per Medicaid benefit
Ohio Medicaid cost-sharing: $0 for all Medicaid recipients — no copays, deductibles, or coinsurance
Total Charges
$524,600
Reimbursement
$42,000 (OH Medicaid FFS) + $198,400 (CareSource) + $25,000 (GEICO TPL) = $265,400
Denials / Appeals
1 denial (IRF admission) — overturned via P2P appeal within 48 hrs