Current through Register 1531, September 27, 2024
(A) All inpatient
services must be provided in accordance with
130 CMR
450.204: Medical Necessity
or
130 CMR
415.415, and are subject, among other things,
to utilization review under
130
CMR 450.207: Utilization Management
Program for Acute Inpatient Hospital through 450.209:
Utilization Management: Prepayment Review for Acute Inpatient Hospitals
and to requirements governing overpayments under
130 CMR
450.235(B):
Overpayments and 450.237: Overpayments:
Determination.
(B)
(1) The MassHealth agency (or its agent) will
review inpatient services provided to members to determine the medical
necessity, pursuant to
130 CMR
450.204: Medical Necessity,
or administrative necessity and appropriateness, pursuant to
130 CMR
415.415, of such services. Any such review
may be conducted prior to, concurrently, or retrospectively following the
member's inpatient admission. Reviewers consider the medical-record
documentation of clinical information available to the admitting provider at
the time the decision to admit was made. Reviewers do not deny admissions based
on what happened to the member after the admission. However, if an admission
was not medically necessary at the time of the decision to admit, but the
medical record indicates that an inpatient admission later became medically
necessary, the admission will be approved as long as all other MassHealth
requirements are met.
(2) If,
pursuant to any review, the Division concludes that the inpatient admission was
not medically or administratively necessary, the Division will deny payment for
the inpatient admission.
(3) If the
Division issues a denial notice for an acute inpatient hospital admission
pursuant to 130 CMR 415.414 and
450.204:
Medical Necessity as well as either
130
CMR 450.209: Utilization Management:
Prepayment Review for Acute Inpatient Hospitals or 450.237:
Overpayments: Determination, the hospital may rebill the claim
as an outpatient service, as long as the Division has determined the service
would have been appropriately provided in an outpatient setting. In order for
the hospital to receive payment under 130 CMR 415.414(B)(3), the outpatient
claim and a copy of the denial notice must be received by the Division within
90 days from the date of the denial notice and must comply with all applicable
Division requirements.
(C) To support the medical necessity of an
inpatient admission, the provider must adequately document in the member's
medical record that a provider with applicable expertise expressly determined
that the member required services involving a greater intensity of care than
could be provided safely and effectively in an outpatient setting. Such a
determination may take into account the amount of time the member is expected
to require inpatient services, but must not be based solely on this factor. The
decision to admit is a medical determination that is based on factors,
including but not limited to the:
(1)
member's medical history;
(2)
member's current medical needs;
(3)
severity of the signs and symptoms exhibited by the member;
(4) medical predictability of an adverse
clinical event occurring with the member;
(5) results of outpatient diagnostic
studies;
(6) types of facilities
available to inpatients and outpatients; and
(7) MassHealth agency's Acute
Inpatient Hospital Admission Guidelines in Appendix F of the
Acute Inpatient Hospital Manual and in various appendices of
other appropriate provider manuals. The MassHealth agency has developed such
guidelines to help providers determine the medical necessity of an acute
inpatient hospital admission. These guidelines indicate when there is generally
no medical need for such an admission.
(D) If, as the result of any review, the
MassHealth agency determines that any hospital inpatient admission, stay, or
service provided to a member was not covered under the member's coverage type
(see
130 CMR 450.105:
Coverage Types) or was delivered without obtaining a required
authorization including, where applicable, authorization from the member's
primary-care provider, the MassHealth agency will not pay for that inpatient
admission, stay, or service.
