Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 31 - SERVICES IN AN INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD)
Section 471-31-006 - UTILIZATION REVIEW
Universal Citation: 471 NE Admin Rules and Regs ch 31 ยง 006
Current through September 17, 2024
Utilization reviews (UR) of Nebraska Medicaid clients residing in an intermediate care facility for individuals with developmental disabilities (ICF/DD) are conducted by the Medicaid review team to determine if clients continue to meet intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care. The utilization review (UR) also evaluates the effectiveness of services provided to clients by intermediate care facilities for individuals with developmental disabilities (ICF/DD). Utilization reviews (UR) will occur at least every six months. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must retain documentation of the utilization review (UR) in the client's permanent record.
006.01 MEDICAID REVIEW TEAM.
006.01(A)
MEDICAID REVIEW TEAM
RESPONSIBILITIES. The Medicaid review team will:
(1) With input from facility staff as needed,
establish a utilization review (UR) schedule for each intermediate care
facility for individuals with developmental disabilities (ICF/DD);
(2) Notify the facility of the utilization
review (UR) at least 30 days prior to the review;
(3) Provide the facility a listing of the
clients that are reviewed;
(4)
Provide direction to the facility regarding forms and records required for the
review:
(5) Determine whether each
client is approved for a continued stay for a maximum of six months or does not
meet criteria for a continued stay. When a continued stay is not approved,
follow the appropriate procedures: and
(6) Notify the facility of the results of the
utilization review (UR).
006.01(A)(i)
EXPANSION OF REVIEW
PROCESS. The Medicaid review team has the authority to expand the
review process as needed and may include the review of additional client
records, and interviews with clients and facility staff. In the event the
Medicaid review team determines the documentation available for review does not
provide adequate information to make a determination of whether the
intermediate care facility for individuals with developmental disabilities
(ICF/DD) level of care is appropriate, the Medicaid review team may conduct
onsite observations and interview with the client at the facility, interview
facility staff, and request additional information from the intermediate care
facility for individuals with developmental disabilities
(ICF/DD).
006.01(B)
INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL
DISABILITIES (ICF/DD). Within 10 days following receipt of the
utilization review results the intermediate care facility for individuals with
developmental disabilities (ICF/DD) must respond to the department in writing,
and must include the following information:
(1) A complete plan of correction that
addresses all identified findings and recommendations:
(2) Changes in level of care;
(3) Each individual recommendations and the
examples of problems: and
(4)
Projected dates of completion on each of the above.
006.01(B)(i)
FAILURE TO
RESPOND. If the facility fails to submit a timely and/or
appropriate response, the Department may take administrative sanctions or any
of the following actions.
(a) The Department
may suspend Title XIX reimbursement for a client or the entire reimbursement
for the facility: or
(b) Clients
may be transferred to another facility.
006.01(C)
COMPOSITION OF THE
MEDICAID REVIEW TEAM. The Medicaid review team must include a
Medicaid reviewer who is knowledgeable in working with individuals with
developmental disabilities and related conditions. The team may also include
any of the following:
(1) A physician:
(2) A registered nurse:
and
(3) Other professional
personnel as needed based on the review process.
006.01(C)(i)
PHYSICIAN. The Department is the final authority for
findings, patient care recommendations, and official action.
006.01(C)(ii)
REGISTERED
NURSE. The registered nurse may consult and participate in the
utilization review (UR) process, should there be potential issues related to
nursing or medical services.
006.01(C)(iii)
OTHER PROFESSIONAL
PERSONNEL. Other professional personnel may consult and
participate in the utilization review (UR) process, based on their expertise
related to services in which the Medicaid review team identified possible
issues.
Disclaimer: These regulations may not be the most recent version. Nebraska 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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