Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment adds the definition of
"written request" which allows the ability to email or fax the record request
letters to providers.
(1) The
following definitions will be used in administering this rule:
(A) Admission. Admission means the act of
registration and entry into a general medical and surgical, psychiatric, or
rehabilitation hospital on the order of a qualified medical practitioner or
medical professional having privileges of admission for the purpose of
providing inpatient hospital services under the supervision of a physician
member of the hospital's medical staff;
(B) Admission certification. Admission
certification means the determination by the medical review agent, as
transmitted to the hospital/physician and the fiscal agent, that the admission
of a participant for inpatient hospital services is approved as medically
necessary, reasonable, and appropriate as to placement at an acute level of
care;
(C) Admitting diagnosis.
Admitting diagnosis means the physician's tentative or provisional diagnosis of
the participant's condition as a basis for examination and treatment when the
admission certification is requested;
(D) Admitting medical professional. Admitting
medical professional means a physician or other person authorized by state
licensure law to order hospital services and who has admission privileges to
order the participant's inpatient admission to the hospital;
(E) Certification number. Certification
number means the number issued by the medical review agent that establishes
that, based upon information furnished by the provider, a participant's
admission for inpatient hospital services is approved as medically necessary;
(F) Department. Department means
the Missouri Department of Social Services;
(G) Emergency admission. Emergency admission
means an admission in which the medical condition manifests itself by acute
symptoms of sufficient severity (including severe pain) that absence of
immediate medical attention could reasonably be expected to result in placing
the patient's health in serious jeopardy, serious impairment to bodily function
or serious dysfunction of any bodily organ or part;
(H) Fee for service. Fee for service refers
to participants and/or services not included in the MO HealthNet Managed Care
program or other prepaid health plans;
(I) Inpatient hospital service. Inpatient
hospital service means a service provided by or under the supervision of a
medical professional after a participant's admission to a hospital and
furnished in the hospital for the care and treatment of the
participant;
(J) Managed Care.
Managed Care is a program under which some MO HealthNet participants are
enrolled with a health plan who contracts with the department to provide a
package of MO HealthNet benefits for a monthly fee per enrollee;
(K) Medical record. Medical record means all
or any portion of the medical record as requested by the medical review agent;
(L) Medical review agent. Medical
review agent means the state's representative who is authorized to make
decisions about admission certifications and validation reviews;
(M) Medically necessary. Medically necessary
means an inpatient hospital service that is consistent with the participant's
diagnosis or condition and is in accordance with the criteria as specified by
the department;
(N) Nurse
reviewer. Nurse reviewer means a person who is employed by or under contract
with the medical review agent and who is licensed to practice professional
nursing in Missouri;
(O) Pertinent
information. Pertinent information means any information that the physician,
hospital, or participant feels may justify or qualify the hospitalization;
(P) Physician reviewer. Physician
reviewer means a physician who is a peer of the admitting/ attending physician
or who specializes in the type of care under review. Exceptions will be made
only if the efficiency or effectiveness of the review would be compromised, but
in every situation the review will be performed by a physician;
(Q) Readmission. Readmission means an
admission that occurs within fifteen (15) days of a discharge of the same
participant from the same or a different hospital. The fifteen- (15-) day
period does not include the day of discharge or the day of readmission;
(R) Participant. Participant means
a person who has applied and been determined eligible for MO HealthNet
benefits;
(S) Reconsideration.
Reconsideration means a review of a denial or withdrawal of admission
certification;
(T) Required
information. Required information means the information to be provided by the
medical professional or hospital to obtain a preadmission or post-admission
certification, which includes participant, medical professional, and hospital
identifying information, admission date, admission diagnosis, procedures,
surgery date, indications for inpatient setting, and plan of care;
(U) Transfer. Transfer means the movement of
a participant after admission from one (1) hospital directly to another or
within the same facility;
(V)
Urgent admission. Urgent admission means a case which requires prompt admission
to the hospital to prevent deterioration of a medical condition from an urgent
to an emergency situation;
(W)
Utilization review assistant. Utilization review assistant means a person who
is employed by or is under contract with the medical review agent who is the
preliminary reviewer to assess the need for nurse review when the Milliman Care
Guidelines is not immediately met;
(X) Validation review. Validation review
means a review conducted after admission certification has been approved. The
review is focused on validating the admitting information and confirming the
determination of medical necessity of the admission; and
(Y) Written Request. A notice to the address
of the provider as listed in the MO HealthNet Division's system, in writing,
transmitted via the U.S. mail or other private or common carrier, facsimile,
e-mail, or any other method/mode of transmittal that is deemed by MO HealthNet
to be an efficient, cost-effective, verifiable, and a reliable method or mode
of communication with the provider, applying provider, or provider's
representative.
(2) As
required by Title 42, Code of Federal Regulations (CFR) part 456, admissions of
MO HealthNet participants to MO HealthNet participating hospitals in Missouri
and bordering states are subject to admission certification procedures and
validation review with the following exceptions:
(A) Admissions of participants enrolled in a
MO HealthNet Managed Care health plan;
(B) Admissions of participants eligible for
both Part A Medicare and MO HealthNet;
(C) Admissions for deliveries;
(D) Admissions for newborns; and
(E) Admissions for certain pregnancy-related
diagnoses. The diagnoses codes for deliveries, newborns, and pregnancy-related
conditions are as published in the ICD (Internal Classification of Diseases,
Clinical Modification) code book. Admissions with diagnoses codes for missed
abortion, pregnancy with abortive outcome, and postpartum condition or
complication will continue to require admission certification and validation
review.
(3) The admission
certification procedure and validation review will be performed by a medical
review agent. The confidentiality of all information shall be adhered to in
accordance with section
208.155,
RSMo and Title 42, CFR part 431, subpart F. The medical review agent's
decisions related to certification or non-certification of MO HealthNet
admissions are advisory in nature. The department is the final payment
authority. The medical review agent's review decisions will be used as the
basis for MO HealthNet reimbursement.
(4) The types of certification and review
include:
(A) Prospective (Preadmission)
certification of nonemergency (elective) admissions of MO HealthNet
participants with established eligibility on date of admission;
(B) Admission (Initial) certification of
emergency and urgent admissions of MO HealthNet participants with established
eligibility on date of admission and obtained prior to discharge;
(C) Continued Stay Review (CSR) to add days
to an existing certification. This review is done prior to discharge or within
fourteen (14) days after discharge;
(D) Retrospective certification (post
discharge) is only appropriate if participant's or provider's eligibility is
not established prior to the patient's discharge date. Other retrospective
certification requests are reviewed on a case by case basis. Retrospective
reviews are not allowed for requests that were initiated while inpatient but
failed to include sufficient clinical information to obtain certification;
(E) Retrospective validation
review of statistically valid sample cases to assure information provided
during admission certification is substantiated by documentation in the medical
record; and
(F) A review of quality
will be performed for those cases selected as part of the focused and random
validation and Certification of Need Samples. Potential quality issues that
represent a minor or less than serious risk to a patient will not be pursued.
However, potentially serious quality issues will proceed through three (3)
levels of specialty physician review if the issue is upheld by the physician
reviewers at the first and second level physician review.
(5) Time requirements for the certification
procedures are as follows:
(A) Medical
professional or hospital notification to the medical review agent of a planned
elective admission must occur no later than two (2) full working days prior to
the date of the planned admission;
(B) Medical professional or hospital
notification to the medical review agent of the occurrence of an emergency or
urgent admission is required by the end of the first full working day after the
date of the actual admission or prior to discharge, whichever comes
first;
(C) Medical professional or
hospital notification to the medical review agent of the need for a continued
stay review must occur prior to discharge or within fourteen (14) working days
after discharge;
(D) The medical
review agent will determine the medical necessity of admissions specified in
subsections (4)(A) and (B) at the time the request is made or by the end of the
next working day after receipt of all required information from the medical
professional or hospital;
(E) The
hospital shall submit, at its own expense, the participant's medical record to
the medical review agent for retrospective certification cases specified in
subsection (4)(D); and
(F) After
receipt of all the required medical record information, the medical review
agent will determine medical necessity of admissions specified in subsection
(4)(D) within thirty (30) calendar days. Cases submitted for physician review
must be completed within this same thirty- (30-) day
period.
(6) The criteria
to be used in the admission certification and validation review are as follows:
(A) Milliman Care Guidelines includes adult
and pediatric criteria for general medical care admissions;
(B) Supplemental criteria sets are included
for adult and child psychiatric care, rehabilitation care and alcohol/drug
abuse treatment;
(C) Ambulatory
procedure screening is done within the Milliman Care Guidelines. If the
procedure meets criteria to be done in the outpatient setting versus inpatient,
the case will be reviewed by a physician for final determination which may
result in denial of the certification request; and
(D) Urgent/emergency criteria are used as
guidelines for determination of type of admission and are defined in section
(1).
(7) The admission
certification procedure is as follows:
(A)
Certification requests can be made in the following manner:
1. For prospective, initial admission, and
continued stay reviews, the medical professional or hospital submits the
request through Cyber Access Web tool or contacts the medical review agent to
provide the required information to obtain certification; or
2. For retrospective certification, the
hospital submits, at its own expense, the participant's medical record to the
medical review agent to obtain certification which is to include the emergency
room record; history and physical; any operative, pathology, or consultation
reports; the first three (3) days of physician or other medical professional
orders including the inpatient admitting orders, progress notes, nurses' notes,
graphic vital signs, medication sheets, and diagnostic testing
results;
(B) Initial
screening of information for reviews in paragraph (7)(A)1. is conducted through
the online Cyber Access Web tool, by utilization review assistants or by nurse
reviewers using the criteria in section (6) as appropriate to the case under
review;
(C) Initial screening of
information for reviews in paragraph (7)(A)2. is conducted by a utilization
review assistant or nurse reviewer using the criteria in section (6) as
appropriate to the case under review;
(D) If the medical information submitted
regarding the patient's condition and planned services meets the applicable
criteria in section (6), the approval decision and a unique certification
number are communicated to the medical professional and hospital via the Cyber
Access Web tool;
(E) If the
applicable criteria in section (6) are not met, the nurse reviewer refers the
case to a physician reviewer for a medical necessity determination. The
physician reviewer is not bound by any criteria and makes the determination
based on medical facts in the case using his/her medical judgment;
(F) If the physician reviewer approves the
admission, the approval determination and unique certification number are
communicated to the medical professional and hospital via the Cyber Access Web
tool;
(G) The attending medical
professional will be contacted prior to a denial determination and allowed the
opportunity to provide additional information. This additional information will
be considered by the physician reviewer prior to a determination to approve or
deny admissions. Determination decisions will be communicated as follows:
1. If the admission is approved, the approval
determination and unique certification number are communicated to the medical
professional and hospital via the Cyber Access Web tool; and
2. Denial determinations are communicated via
mail to the medical professional, hospital, and participant. The status can
also be found on the Cyber Access Web tool;
(H) The medical professional, hospital, or
participant who is dissatisfied with an initial denial determination is
entitled to a reconsideration review by the medical review agent as outlined in
section (8); and
(I) If inpatient
admission is approved and surgery is planned, day of surgery admission will be
required unless the physician reviewer approves a preoperative day for
evaluating concurrent medical conditions or other risk
factors.
(8)
Reconsideration Review Requests. The medical review agent's denial decisions
relate to medical necessity and appropriateness of the inpatient setting in
which services were furnished or are proposed to be furnished. The procedure to
request reconsideration of an initial denial determination is as follows:
(A) Time Requirements;
1. To request a reconsideration review for a
patient for a prospective admission or for a patient still in the hospital, the
provider should telephone a request to the medical review agent. In either of
these situations, the request for reconsideration must be received within three
(3) working days of receipt of the written denial notice. In order to expedite
the process, the provider must indicate that this is a request for a
reconsideration review. The medical review agent will complete the
reconsideration review and issue a determination within three (3) working days
of receipt of the request and all pertinent information; and
2. If the patient has been discharged from
the hospital, the provider must submit a request for reconsideration in writing
or by facsimile (fax). This reconsideration cannot be requested by telephone.
The request must be made within sixty (60) calendar days of receipt of the
written denial notice. The medical review agent will complete the
reconsideration review within thirty (30) calendar days after receipt of the
request for reconsideration review, medical records, and all pertinent
information. A written notice will be issued to the participant, medical
professional, and hospital within three (3) working days after the
reconsideration review is completed. This information may also be accessed
through the Cyber Access Web tool;
(B) The reconsideration review shall consist
of a review of all medical records and additional documentation submitted by
any one of the parties receiving the initial denial notice;
(9) Validation Sample of Approved Admissions.
(A) A quarterly validation sample of approved
admissions will be selected to ensure that the information provided during the
certification process is substantiated by documentation and clinical findings
in the medical record.
(B) The
sample size will be a statistically valid number of certified
admissions.
(C) For admissions
subject to a validation review, the medical review agent will request medical
records. Providers have thirty (30) calendar days from the date of written
request to submit documentation. At rates determined by state statute 191.227,
RSMo, provider costs associated with submission of requested documentation will
be reimbursed regardless of the medium used for submission. Records not
received within the thirty (30) days will result in the admission being denied
and claim payment recouped.
(D)
Admission certification is not a guarantee of MO HealthNet payment. If the
information provided during the certification process cannot be validated in
the medical record by a nurse reviewer using the criteria in section (6), or
was false, misleading or incomplete, the case will be referred to a physician
reviewer for a medical necessity determination. The physician reviewer is not
bound by any criteria and makes the determination based on medical facts in the
case using his/her medical judgment.
(E) The medical professional or hospital will
be allowed an opportunity to respond to a proposed denial prior to issuance of
a final denial notice.
(F) If the
physician reviewer determines the admission was not medically necessary, a
denial notice will be issued to all parties. Reconsideration review procedures
in section (8) apply to this review.
(G) A validation review determination of
denial will result in recovery of MO HealthNet payments in accordance with
13 CSR
70-3.030. Overpayment determinations may be appealed
to the Administrative Hearing Commission within thirty (30) days of the date of
the notice letter if the sum in dispute exceeds five hundred dollars
($500).
(H) Review of the quality
of care will also be performed on the validation review sample. Potentially
serious quality of care issues identified by the nurse reviewer will be
referred to a physician of the medical review agent.
(10) As specific in relation to
administration of the provisions of this rule and not otherwise inconsistent
with participant liability as determined under provisions of
13
CSR 70-4.030, participant liability issues for
admission certification and validation review are as follows:
(A) The participant is liable for inpatient
hospital services in the following circumstances:
1. When the prospective request for
certification is denied and the participant is notified of the denial but the
participant chooses to be admitted, s/he is liable for all days;
2. When an admission request for
certification is denied, the participant is liable for those days of inpatient
hospital service provided after the date of the denial notification to him/her
;
3. When the participant's
eligibility was not established on or by the date of admission and the request
for certification is denied, the participant is liable for all days;
and
4. When the participant has
signed a written agreement with the provider indicating that MO HealthNet is
not the intended payer for the specific item or service, s/he is liable for all
days. The agreement must be signed prior to receiving the services. In this
situation, the participant accepts the status and liabilities of a private pay
patient in accordance with
13
CSR 70-4.030; and
(B) The participant is not liable for
inpatient hospital services in the following circumstances:
1. When the provider fails to comply with
prospective certification requirements, the participant is not liable for any
days;
2. When an admission request
for certification of an admission is denied, the participant is not liable for
those days of inpatient hospital service provided prior to and including the
date of the notification to him/her of the denial; and
3. When the medical review agent performs a
validation review as provided in section (9) of this rule and determines an
admission was not medically necessary for inpatient services, the participant
is not liable for any days.
(11) Continued stay reviews, when necessary,
will be performed for all fee-for-service MO HealthNet participants subject to
admission certification to determine that services are medically necessary and
appropriate for inpatient care. The continued stay review procedure is as
follows:
(A) When extended hospitalization is
indicated beyond the initial length of stay assigned by the medical review
agent for prospective or admission certification, the hospital and attending
medical professional are required to provide additional medical information to
warrant the continued hospital stay as well as request the number of additional
days needed prior to discharge or within fourteen (14) working days after
discharge. If the request for continued stay review is received fifteen (15) or
more working days post discharge, it is considered a retrospective review and
the requirements mentioned in subsection (5)(E) will apply;
(B) For continued stay reviews, either
initiated via the Cyber Access Web tool or the telephone, the Milliman Care
Guidelines will be applied to any additional diagnosis or surgical procedures
indicated. The medical professional and/or hospital may also upload any
additional supporting documentation into the Cyber Access Web tool;
(C) A physician will review cases when
continued stay is requested beyond the Milliman Care Guidelines. The physician
reviewer shall approve or deny the continued stay days;
(D) The requesting medical professional and
hospital are notified in cases of denial only. All others are found on the
Cyber Access Web tool; and
(E)
Information contained in sections (8)-(10) of this rule also apply to continued
stay reviews.
(12)
Continued stay reviews will be performed for diagnoses relating to alcohol and
drug abuse to determine that services are medically necessary and appropriate
for inpatient care. The continued stay review procedure for alcohol and drug
abuse detoxification services is as follows:
(A) At the time of admission certification,
as described in section (7) of this rule, the hospital or attending medical
professional shall specify the anticipated medically necessary
length-of-stay;
(B) If the
applicable criteria in section (6) of this rule is met, the utilization review
assistant or nurse reviewer shall assign a number of days not to exceed three
(3) days;
(C) If an extension of
services is required, the hospital or attending medical professional shall
contact the medical review agent either by the Cyber Access Web tool or by
telephone to request additional days for inpatient hospital care. If the
applicable criteria in section (6) of this rule is met, the utilization review
assistant or nurse reviewer shall assign a total length-of-stay days not to
exceed five (5) days;
(D) If either
the applicable criteria in section (6) of this rule is not met or the total
length-of-stay exceeds five (5) days, the case shall be referred to a physician
reviewer. The physician reviewer is not bound by the criteria in section (6) of
this rule and makes the determination based on medical facts in the case using
his/her medical judgment. The physician reviewer shall approve or deny the
admission or continued stay days; and
(E) The medical professional and hospital are
notified of the review decision as stated in section (7) of this rule.
(13) The MO HealthNet
program, in accordance with 191.710, RSMo, will request that hospital providers
report all re-hospitalizations of infants born premature at earlier than
thirty-seven (37) weeks gestational age within their first six (6) months of
life.
(14) Large case management
will be performed for fee-for-service participants with potentially
catastrophic conditions whenever specific trigger diagnoses or other qualifying
events are met.
(A) Large case management
procedures for fee-for-service participants are as follows:
1. Preadmission review nurses identify
patients who may qualify and benefit from case management, and refer these
cases to a case manager of the medical review agent. Cases include, but are not
limited to, the following:
A. Patients with
high costs or anticipated high costs; or
B. Patients with repeated admissions or
unusually long lengths-of-stay; or
C. Patients who encounter significant
variances from the intervention or from expected outcomes associated with a
clinical path; or
D. Patients who
meet one (1) or more of the indicators on the Trigger Diagnosis/Qualifying
Events list;
2. The
medical review agent will complete an initial screening which will include a
review of the medical information and interviews with the health care providers
and patient, if needed or feasible;
3. An in-depth assessment will be conducted,
which will include evaluation of the patient's health status, health care
treatment and service needs, support system, home environment, and physical and
psychosocial functioning. The assessment will be used to recommend one (1) of
the following:
A. Reassessment later;
or
B. No potential for case
management; or
C. Active monitoring
in anticipation of a future plan for alternative treatment; or
D. An alternative treatment plan is
indicated;
4. If an
alternative treatment plan is indicated, the medical review agent will
collaborate with the patient's attending medical professional to develop an
alternative treatment plan. The attending medical professional is responsible
for implementation of the alternative treatment plan; and
5. The medical review agent will monitor and
assess the effectiveness of the case management and will report to the
state.
*Original authority: 208.201, RSMo
1987.