Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.94 - Special Pediatric Hospitals
Section 10.09.94.06 - Utilization Review
Universal Citation: MD Code Reg 10.09.94.06
Current through Register Vol. 51, No. 19, September 20, 2024
A. The Department or its designee shall conduct utilization review to determine that special pediatric hospital admissions and outpatient services are authorized only when medically necessary.
B. Review Procedure.
(1) For all admissions, the
special pediatric hospital shall provide:
(a)
The elements of a participant's medical record specified by the Department or
its designee for preadmission review, and request to certify the participant's
admission; and
(b) Sufficient
clinical information or documentation to the Department or its designee that
supports the need for admission to a special pediatric hospital including, but
not limited to:
(i) Current medical health
status;
(ii) Treatment received to
date;
(iii) Proposed treatment plan
for requested admission; and
(iv)
Expected length of stay.
(2) Admission for inpatient services may be
authorized only when these services cannot be provided:
(a) On an outpatient basis; or
(b) In a facility that is licensed to provide
a more appropriate level of care to the participant.
(3) Concurrent review shall be conducted as
long as the participant remains hospitalized, based on the participant's
diagnosis and condition, to ensure the medical necessity of the participant's
inpatient stay, at the following intervals:
(a) After an initially authorized 14-day
stay, or at the end of the expected length of stay identified at admission,
whichever comes first; and
(b)
Every 14 days following the initial concurrent review, in a form and including
clinical documentation as specified by the Department or its
designee.
(4) The
Department or its designee may conduct on-site reviews after an initially
authorized period of 30 days, and every 30 days thereafter until
discharge.
(5) An elective
inpatient hospital admission requires preadmission authorization by the
Department or its designee.
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 has been determined to no
longer require special pediatric 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 in a lower-acuity 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 special pediatric 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(l) 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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