Current through Register Vol. 49, No. 13, September 23, 2024
Subpart
1.
Requirement for admission certification.
Except as provided in subpart
2, a hospital or admitting
physician furnishing inpatient hospital services to a recipient must obtain
admission certification in order for the admitting physician, the hospital, or
other provider of an inpatient hospital service to receive medical assistance
payment for the inpatient hospital services to the recipient.
A. Admission certification must be obtained
when a recipient is admitted, readmitted, or transferred to a hospital unless
the admission is combined under the readmission criteria of part
9505.0540.
B. An admission certification number is valid
only for the hospital admission for which it is issued, except in circumstances
specified in part
9505.0540.
C. Admission certification for the admission
of a MinnesotaCare recipient must be requested within 30 days of the date of
admission or be subject to penalties under Minnesota Statutes, section
256L.03,
subdivision 3, paragraph (b).
Subp.
2.
Exclusions from admission certification.
Admissions for inpatient hospital services under items A to C
shall be excluded from the requirement in subpart
1. The admissions are subject
to retrospective review as stated in subpart
10.
A. The admission of a pregnant woman that
results in the delivery of a newborn or a stillbirth, and the admission of a
newborn resulting from birth.
B.
The admission is for Medicare Part A covered inpatient hospital services which
are provided to a recipient who is also eligible for medical assistance and for
which medical assistance payment is requested for the coinsurance and
deductible payments only.
C. An
admission to a hospital that is not located in Minnesota or the local trade
area for which a prior authorization has been obtained according to parts
9505.5000 to
9505.5030.
Subp. 3.
Admitting physician and
hospital responsibilities.
The admitting physician or hospital that seeks medical
assistance payment for inpatient hospital services provided to a recipient must
follow the procedures in items A to C.
A. Request admission certification by
contacting the medical review agent either by telephone or in writing and
providing the information in subitems (1) to (8):
(1) hospital's medical assistance provider
number and name;
(2) recipient's
name, recipient ID number, sex, and date of birth;
(3) admitting physician's name and medical
assistance provider number;
(4)
primary procedure, or principal procedure, when applicable, according to the
most recent edition of Current Procedural Terminology published by the American
Medical Association or the International Classification of Diseases -- Clinical
Modification, published by the Practice Management Information Corporation,
4727 Wilshire Boulevard, Los Angeles, CA 90010 which are incorporated by
reference. These books are available through the Minitex interlibrary loan
system and are subject to change;
(5) date of admission, or expected date of
admission;
(6) whether the
admission is a readmission or a transfer;
(7) admitting diagnosis, or principal
diagnosis, when applicable, according to the most recent edition of the
International Classification of Diseases -- Clinical Modification;
and
(8) information from the plan
of care and the reason for admission as necessary for the medical review agent
to determine if admission is or was medically necessary.
B. Inform all providers involved in the
recipient's inpatient hospital services of the certification number.
C. For purposes of billing, enter the
certification number on invoices submitted to the department for
payment.
Subp. 4.
[Repealed, 23 SR 298]
Subp. 5.
[Repealed, 23 SR 298]
Subp. 6.
[Repealed, 23 SR 298]
Subp. 7.
Ineligibility to serve as physician or physician adviser.
A physician shall not be eligible to determine the medical
necessity of an admission under parts
9505.0501 to
9505.0545 if:
A. the physician is the admitting physician
for the admission for which certification is being requested;
B. during the previous 12 months, the
physician issued treatment orders or participated in the formulation or
execution of the treatment plan for the recipient for whom admission
certification is requested;
C. the
physician and the physician's family, which means the physician's spouse,
child, grandchild, parent, or grandparent, has an ownership interest of five
percent or more in the hospital for which admission certification is being
requested; or
D. the physician can
obtain a financial benefit from the admission of the recipient.
Subp. 8.
Procedure for
admission certification.
The procedures for admission certification are listed in
items A to I.
A. Upon receipt of the
information requested in subpart
3, item A, the medical review
agent shall review the information and determine whether the admission is
medically necessary.
B. If the
medical review agent determines that the admission is medically necessary, the
medical review agent shall issue a certification number.
C. If the medical review agent is unable to
determine that the admission is medically necessary, the medical review agent
shall contact a physician.
D. If
the physician determines that the admission is medically necessary, the medical
review agent shall issue a certification number.
E. If the physician determines that the
admission is not medically necessary or is unable to determine that the
admission is medically necessary, the medical review agent shall notify the
provider by telephone, and the provider may request within 24 hours of the
medical review agent's notification, exclusive of weekends and holidays, a
second physician's opinion.
F. If
the provider requests a second physician's opinion, the medical review agent
shall contact a second physician. If the second physician determines that the
admission is medically necessary, the medical review agent shall issue a
certification number.
G. If the
second physician determines that the admission is not medically necessary, or
is unable to determine that the admission is medically necessary, or if the
provider does not request a second physician's opinion when the first physician
determines that the admission is not medically necessary or is unable to
determine that the admission is medically necessary, then the medical review
agent shall deny the admission certification and shall not issue a
certification number.
H. The
medical review agent shall make the determination about medical necessity and
inform the provider by telephone within 24 hours of the receipt of the
information requested in subpart
3, item A, exclusive of
weekends and holidays, unless the provider requests a second physician's
opinion. If the provider requests a second physician's opinion, the medical
review agent shall make the determination of medical necessity and notify the
provider by telephone within 24 hours of the request, exclusive of weekends and
holidays. The medical review agent shall send a written notice of the
determination to the hospital and admitting physician within five working days
of the determination. In the case of a denial, the written notices to the
hospital and the admitting physician required under this item must be sent by
certified mail. The denial notices to the admitting physician and hospital must
state the reasons for the denial and inform the admitting physician or hospital
that a reconsideration may be requested under subpart
9. In the case of a denial
when the recipient has not received the inpatient hospital services, the
medical review agent shall send a written notice of the denial to the recipient
within five working days of the determination. The denial notice to the
recipient must state the recipient's right of appeal under part
9505.0545 and Minnesota Statutes,
section
256.045.
I. When there is a need to further
substantiate the medical necessity of the admission, the department or medical
review agent may request that the provider submit, at the provider's expense, a
copy of the recipient's medical record or part of the medical record needed to
make the determination. If the provider fails to submit a requested record
within 30 days of the date of the request, the department or the medical review
agent shall make a determination based on the information available.
Subp. 9.
Reconsideration
requested.
The admitting physician or the hospital may request
reconsideration of a decision to deny or withdraw an admission certification
if:
A. the medical review agent denies
an admission certification number because the admission is not medically
necessary;
B. the medical review
agent withdraws an admission certification number for all or part of a
recipient's stay because all or part of the stay was not medically necessary
based on a concurrent or retrospective review; or
C. the medical review agent denies or
withdraws an admission certification number or considers an admission and
readmission to be a transfer under the readmission criteria in part
9505.0540 because the admission
and readmission meet the criteria specified in part
9505.0540.
The admitting physician or the hospital shall submit a
written request for reconsideration to the medical review agent within 30 days
of the date of receipt of the certified letter from the medical review agent
denying or withdrawing the admission certification number. The request must
include the recipient's name and the recipient's ID number; the disputed
admission; the reason for the dispute; the medical record or the part of the
medical record needed to make a determination of the medical necessity of the
admission or appropriateness of a readmission and any other information related
to the admission and determination; and the name, address, and telephone number
of the person to contact about the reconsideration.
Subp. 9a. [Repealed, 23 SR
298]
Subp. 9b.
Reconsideration; physician advisers appointed by medical review
agent.
Upon receipt of a request for reconsideration under subpart
9, the medical review agent
shall appoint at least three physician advisers who did not take part in the
decision to deny or withdraw all or part of the admission certification. Each
physician adviser shall determine the medical necessity of the admission or the
continued stay or, in the case of a readmission, determine whether the
admission and readmission meet the criteria in part
9505.0540. The reconsideration
decision must be the majority opinion of the physician advisers. In making the
decision, the three physician advisers shall use the criteria of medical
necessity set out in part
9505.0530.
Subp. 9c.
Completion of
reconsideration.
The medical review agent shall complete the reconsideration
requested under subpart
9 within 60 days of receipt
of the information required under subpart
9. The medical review agent
shall notify the provider who requested the reconsideration, by telephone, of
the decision within 24 hours of receipt of the physician adviser's
determination, exclusive of weekends and holidays. A written notice of the
decision must be sent by certified mail to the hospital and the admitting
physician by the medical review agent within ten working days of the receipt of
the physician adviser's determination. In the event a denial is upheld, the
notice must inform the admitting physician and hospital of the right to request
an appeal of the reconsideration decision within 30 days of receiving the
notice according to Minnesota Statutes, section
256.9685,
subdivisions 1b to 1d.
Subp.
10.
Medical record review and determination after
admission.
The department or the medical review agent may conduct a
concurrent, continued stay or retrospective review of a recipient's medical
record to establish the recipient's diagnosis and procedure codes and to
determine whether the recipient's admission and all the inpatient hospital
services provided to the recipient were medically necessary, whether a
continued stay was medically necessary or will be medically necessary, and
whether all medically necessary inpatient hospital services were provided to
the recipient. In making a determination under this subpart, the medical review
agent must follow the procedure in items A to G.
A. The medical review agent shall review the
medical record to establish the diagnosis and procedure codes for diagnostic
category validation. Additionally, the medical review agent may review the
bills, invoices, and all supporting documentation pertaining to a request for
medical assistance payment.
B. The
medical review agent may request additional information from the admitting
physician or the hospital as necessary to clarify the medical record if the
medical review agent is unable to determine that the recipient's admission was
medically necessary, that all inpatient hospital services provided to the
recipient were medically necessary, that the recipient's continued stay was
medically necessary or will be medically necessary, or that all medically
necessary inpatient hospital services were provided. The additional information
must be submitted at the expense of the admitting physician or
hospital.
C. If, after additional
information is submitted, the medical review agent is unable to determine that
the recipient's admission was medically necessary, that the recipient's
continued stay was medically necessary or will be medically necessary, or that
all medically necessary inpatient hospital services were provided, the medical
review agent must consult a physician.
D. If a physician determines that the
recipient's admission was not medically necessary, or that all medically
necessary inpatient hospital services were not provided, the medical review
agent shall withdraw the previously issued certification number and shall
notify the admitting physician and hospital of the determination by certified
letter mailed within five working days. The notice shall state the right of the
admitting physician and hospital to request a reconsideration under subpart
9.
E. If a physician determines that the
recipient's continued stay was not medically necessary or will not be medically
necessary, the portion of the stay determined not to be medically necessary
will be denied. If the recipient is still an inpatient, the medical review
agent shall notify the admitting physician and hospital of the determination by
telephone within 24 hours of receipt of the determination, exclusive of
weekends and holidays, and by certified letter mailed within five working days
of receipt of the determination. If the recipient has been discharged, the
medical review agent shall notify the admitting physician and hospital of the
determination by certified letter mailed within five working days of receipt of
the determination. The notice must state the right of the admitting physician
and hospital to request a reconsideration under subpart
9.
F. If recertification of a recipient's need
for inpatient hospital services was required but was not documented in the
medical record, the medical review agent shall deny that portion of the
admission that was not recertified.
G. If the medical review agent is unable to
determine from the documentation in the recipient's medical records the reasons
for the recipient's discharge and readmission according to criteria in part
9505.0540, the medical review
agent shall submit the medical records of the recipient's admission and
readmission to a physician. The physician shall review the records and
determine the nature of the discharge and readmission according to the criteria
in part
9505.0540, and if the
determination of the medical review agent is different from that of the
admitting physician or hospital, then the medical review agent shall notify the
admitting physician and hospital by certified letter mailed within five working
days. The notice must state the right of the admitting physician and hospital
to request a reconsideration under subpart
9.
Subp. 11.
Payment adjustments.
The department may make payment adjustments according to the
circumstances in items A to E.
A. For
hospitals receiving payments under parts
9500.1090 to
9500.1140, and admitting
physicians and other providers of inpatient hospital services receiving
payments through medical assistance, if the admission was not medically
necessary or the medical record does not adequately document that the admission
was medically necessary, the entire payment shall be denied or recovered. If
the hospital, admitting physician, and other providers of inpatient hospital
services failed to provide inpatient hospital services that were medically
necessary, the department may take action under parts
9505.2160 to
9505.2245.
B. For hospitals receiving payments under
parts
9500.1090 to
9500.1140, and admitting
physicians and other providers of inpatient hospital services receiving
payments through medical assistance, if the admission was medically necessary
but some or all of the additional inpatient hospital services were not or will
not be medically necessary, or the medical record does not adequately document
that the additional inpatient hospital services were or will be medically
necessary, payment for the additional services shall be denied or recovered. If
the hospital, admitting physician, and other providers of inpatient hospital
services failed to provide inpatient hospital services that were medically
necessary, the department may take action under parts
9505.2160 to
9505.2245.
C. If the diagnostic category validation
indicates a discrepancy between the diagnostic category assigned to the claim
and the diagnostic category established from the medical record, the department
shall adjust the payment as applicable to the diagnostic category that is
accurate for the recipient's condition according to the medical
record.
D. If, within 30 days, the
hospital failed to comply with the department's or the medical review agent's
request to submit the medical record or other required information, all or part
of the payment shall be denied or recovered as provided in items A to
C.
E. The provider may not seek
payment from the recipient for inpatient hospital services provided under parts
9505.0501 to
9505.0545 if the certification
number is not issued or is withdrawn.
Subp. 12. [Repealed, 23 SR 298]
Subp. 13. [Repealed, 23 SR 298]
Subp. 14. [Repealed, 23 SR 298]
Subp. 15. [Repealed, 23 SR 298]
Statutory Authority: MS s 256.0625;
256.9353;
256.991;
256B.04;
256B.503;
256D.03