Current through Register Vol. 42, No. 11, August 30, 2024
(1) Certification of need for inpatient
hospital services is a determination which is made by the certifying team as
specified in (4) below regarding the Medicaid recipient's treatment needs for
admission to the facility.
(2) The
appropriate team must certify that:
(a)
Ambulatory care resources available in the community do not meet the treatment
needs of the recipient;
(b) Proper
treatment of the recipient's psychiatric condition requires services on an
inpatient basis under the direction of a physician; and
(c) The services can reasonably be expected
to improve the recipient's condition or prevent further regression so that the
services will no longer be needed.
(3) The appropriate certifying team must
complete the PSY-2 form which is the certification of need for inpatient
hospital services.
(4)
Certification of need for services must be made by teams specified as follows:
(a) For an individual who is a Medicaid
recipient and is a nonemergency admission to the facility the certification of
need for services must be made prior to the admission. If the certification is
completed subsequent to admission, payment cannot be made for the period prior
to the date the certification is completed. Certification must be made by an
independent team that:
1. Includes a
physician;
2. Has competence in
diagnosis and treatment of mental illness, preferably in child psychiatry;
and
3. Has knowledge of the
individual's situation.
(b) Certification of need for services may be
made by the team as specified in Rule
560-X-41-.04(4)(a)
provided the team is not:
1. Employed and
reimbursed by the facility, or
2.
In partnership with the attending physician, or
3. On the treatment team caring for the
patient.
(c) For an
individual who applies for Medicaid while in the facility, the certification of
need for services must:
1. Be made by the
team responsible for the plan of care as specified in Rule
560-X-41-.06(3),
and
2. Cover any period before
application for which claims are made.
3. If the certification is completed
subsequent to the filing of the application, payment cannot be made for the
period prior to the date the certification is completed.
(d) For emergency admissions the
certification of need for services must be made by the team responsible for the
plan of care as specified in Rule
560-X-41-.06(3)
within 14 working days after admission.
(5) An emergency admission is described as a
situation where the patient's condition is such that prompt provision of care
is necessary to prevent the death or serious impairment of the health of the
patient or others due to the individual's psychiatric condition. The presence
of a court order does not in itself justify characterizing an admission as an
emergency.
Author: Lynn Sharp, Associate Director,
Institutional Services
Statutory Authority: State Plan, Attachment
3.1-A, pp. 7, 7.16; 42 C.F.R. §§441, Subpart D.
