Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.93 - Chronic Hospitals
Section 10.09.93.08 - Utilization Review
Universal Citation: MD Code Reg 10.09.93.08
Current through Register Vol. 51, No. 19, September 20, 2024
A. Admission and Prior Approval.
(1) For participants and
individuals who have applied for Medical Assistance, the provider shall request
a determination from the Department or its designee at the time of admission,
or at the time of application for Medical Assistance, that the individual meets
the medical eligibility criteria set forth in Regulation .07A of this
chapter.
(2) For a participant to
be preauthorized for services in a brain injury community integration program,
a provider that meets the requirements of Regulation .04 of this chapter shall
request a determination from the Department or its designee that the
participant meets the criteria set forth in Regulation .07B of this
chapter.
(3) If the provider
obtains the determination set forth in §A(1) or (2) of this regulation
after admission, the eligibility determination shall be effective on the date
that the determination was requested.
B. Concurrent Review.
(1) On a monthly basis, the provider shall
notify the Department or its designee of all persons who have:
(a) Received an initial determination of
medical eligibility for chronic hospital services;
(b) Been determined to continue to meet
medical eligibility criteria for chronic hospital services;
(c) Been discharged; or
(d) Been determined to no longer be medically
eligible.
(2) Concurrent
review shall be conducted every 14 days as long as the participant remains
hospitalized to ensure the medical necessity of the participant's inpatient
stay
(3) The Department or its designee may
conduct on-site reviews.
C. Administrative Days.
(1) To be paid for administrative days, the
provider shall document, in a form designated by the Department, information
which satisfies the conditions listed below:
(a) The participant who was initially
eligible has been determined to no longer require chronic hospital services,
and the provider has:
(i) Received a
determination from the Department or its designee that the participant requires
the level of service provided by a nursing facility but an appropriate facility
is not available;
(ii) Established
a plan for discharge during the period of administrative days, is actively
pursuing placement at an appropriate level of care for the participant, and has
documented this activity in the participant's record; and
(iii) Submitted documentation to the
Department or its designee that placement activity was conducted no fewer than
3 days per week during the period for which payment is requested for
administrative days; or
(b) The participant is no longer medically
eligible to receive chronic hospital services but cannot be moved, and the
following conditions are met:
(i) The medical
reason the participant cannot be moved is documented by the attending physician
in the participant's medical record;
(ii) The attending physician reevaluates the
medical cause of the participant's inability to be moved at least once every 7
days; and
(iii) The provider
documents the active treatments used to resolve the medical cause of the
participant's inability to be moved;
(2) To receive reimbursement for
administrative days, the provider shall document that it has met the conditions
of §C(1) of this regulation, at least every 14 days.
(3) Documentation shall be submitted to the
Department or its designee no later than 3 business days following the end of
the 14-day period.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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