Current through Register Vol. 35, No. 18, September 24, 2024
MAD coverage of some inpatient services may be conditional or
limited.
A. Medically warranted days:
A general hospital is not reimbursed for days of acute level inpatient services
furnished to an eligible recipient as a result of difficulty in securing
alternative placement. A lack of nursing facility placement is not sufficient
grounds for continued acute-level hospital care.
B. Awaiting placement days:
(1) When the MAD utilization review (UR)
contractor determines that an eligible recipient no longer meets the care
criteria in a rehabilitation, extended care or other specialty hospital or PPS
exempt rehabilitation hospital but requires a nursing facility level of care
which may not be immediately located, those days during which the eligible
recipient is awaiting placement in a lower level of care facility are termed
"awaiting placement days". Payment to the hospital for awaiting placement days
is made at the weighted average rate paid by MAD for the level of nursing
facility services required by the eligible recipient (high NF or low
NF).
(2) When the MAD UR contractor
determines that a recipient under 21 years of age no longer meets acute care
criteria and it is verified that an appropriate reviewing authority has made a
determination that the eligible recipient requires a residential level of care
which may not be immediately located, those days during which the eligible
recipient is awaiting placement to the lower level of care are termed "awaiting
placement days". MAD does not cover residential care for individuals over 21
years of age.
(3) Payment to the
hospital for awaiting placement days is made at the weighted average rate paid
by MAD for residential services that may have different levels of
classification based on the medical necessity for the placement of the eligible
recipient. See 8.302.5 NMAC, Prior Authorization and Utilization
Review. A separate claim form must be submitted for awaiting placement
days.
(4) MAD does not pay for any
ancillary services for "awaiting placement days". The rate paid is considered
all inclusive. Medically necessary physician visits or, in the
case of the eligible recipient under 21 years of age requiring residential
services, licensed Ph.D. psychologist visits, are not included in this
limitations.
C. Private
rooms: A hospital is not reimbursed for the additional cost of a private room
unless the private room is medically necessary to protect the health of the
eligible recipient or others.
D.
Services performed in an outpatient setting: MAD covers certain procedures
performed in an office, clinic, or as an outpatient institutional service which
are alternatives to hospitalization. Generally, these procedures are those for
which an overnight stay in a hospital is seldom necessary.
(1) An eligible recipient may be hospitalized
if there is an existing medical condition which predisposes the eligible
recipient to complications even with minor procedures.
(2) All claims for one- or two-day stays for
hospitalization are subject to prepayment or post-payment review.
E. Observation stay: If a
physician orders an eligible recipient to remain in the hospital for less than
24 hours, the stay is not covered as inpatient admission, but is classified as
an observation stay. An observation stay is considered an outpatient service.
(1) The following are exemptions to the
general observation stay definition:
(a) the
eligible recipient dies;
(b)
documentation in medical records indicates that the eligible recipient left
against medical advice or was removed from the facility by their legal guardian
against medical advice;
(c) an
eligible recipient is transferred to another facility to obtain necessary
medical care unavailable at the transferring facility; or
(d) an inpatient admission results in
delivery of a child.
(2)
MAD or its designee determines whether an eligible recipient's admission falls
into one of the exempt categories or considers it to be a one- or two-day stay.
(a) If an admission is considered an
observation stay, the admitting hospital is notified that the services are not
covered as an inpatient admission.
(b) A hospital must bill these services as
outpatient observation services. However, outpatient observation services must
be medically necessary and must not involve premature discharge of an eligible
recipient in an unstable medical condition.
(3) The hospital or attending physician can
request a re-review and reconsideration of the observation stay decision. See
MAD 953, Reconsideration of Utilization Review
Decisions.
(4) The
observation stay review does not replace the review of one- and two-day stays
for medical necessity.
(5) MAD does
not cover medically unnecessary admissions, regardless of length of
stay.
F. Review of
hospital admissions: All cases requiring a medical peer review decision on
appropriate use of hospital resources, quality of care or appropriateness of
admission, transfer into a different hospital, and readmission are reviewed by
MAD or its designee. MAD or its designee performs a medical review to verify
the following:
(1) admission to acute care
hospital is medically necessary;
(2) all hospital services and surgical
procedures furnished are appropriate to the eligible recipient's condition and
are reasonable and necessary to the care of the eligible recipient;
(3) patterns of inappropriate admissions and
transfers from one hospital to another are identified and are corrected;
hospitals are not reimbursed for inappropriate admissions or transfers;
and
(4) the method of payment and
its application by a hospital does not jeopardize the quality of medical
care.
G. Non-covered
services: MAD does not cover the following specific inpatient benefits:
(1) a hospital service which is not
considered medically necessary by MAD or its designee for the condition of the
eligible recipient;
(2) a hospital
service that requires prior authorization for which the approval was not
requested except in cases with extenuating circumstances as granted by MAD or
its designee;
(3) a hospital
service which is furnished to an individual who was not eligible for MAD
services on the date of service;
(4) an experimental or investigational
procedure, technology or therapy and the service related to it, including
hospitalization, anesthesiology, laboratory tests, and imaging services; see
MAD-765, Experimental or Investigational Procedures or
Therapies;
(5) a drug
classified as "ineffective" by the federal food and drug
administration;
(6) private duty or
incremental nursing services;
(7)
laboratory specimen handling or mailing charges; and
(8) formal educational or vocational training
services which relate to traditional academic subjects or training for
employment.
H. Covered
services in hospitals certified for emergency services-only: Certain inpatient
and outpatient services may be furnished by a hospital certified to participate
in the Title XVIII (medicare) program as an emergency hospital. MAD reimburses
a provider only for treatment of conditions considered to be medical or
surgical emergencies. "Emergency" is defined as a condition which develops
unexpectedly and needs immediate medical attention to prevent the death or
serious health impairment of the eligible recipient which necessitates the use
of the most accessible hospital equipped to furnish emergency services.
(1) MAD covers the full range of inpatient
and outpatient services furnished to an eligible recipient in an emergency
situation in a hospital which is certified for emergency
services-only.
(2) MAD
reimbursement for emergency services furnished in a hospital certified for an
emergency services-only is made for the period during which the emergency
exists.
(a) Documentation of the eligible
recipient's condition, the physician's statement that emergency services were
necessary, and the date when, in the physician's judgment, the emergency
ceased, must be attached to the claim form.
(b) An emergency no longer exists when it
becomes safe from a medical standpoint to move the eligible recipient to a
certified inpatient hospital or to discharge the eligible recipient.
(c) Reimbursement for services in an
emergency hospital is made at a percentage of reasonable charges as determined
by HCA. No retroactive adjustments are made.
I. Patient self determination act: An adult
eligible recipient must be informed of their right to make health decisions,
including the right to accept or refuse medical treatment, as specified in the
Patient Self-Determination Act. See 8.302.1 NMAC, General Provider
Policies.
J. Psychiatric
services furnished to an eligible recipient under 21 years of age in PPS-exempt
units of acute care hospitals: Services furnished to an eligible recipient must
be under the direction of a physician. In the case of psychiatric services
furnished to an eligible recipient under 21 years of age, these services must
be furnished under the direction of board eligible/board certified
psychiatrist, or a licensed psychologist working in collaboration with a
similarly qualified psychiatrist. The psychiatrist must conduct an evaluation
of the eligible recipient, in person, within 24 hours of admission. In the case
of an eligible recipient under 12 years of age, the psychiatrist must be board
eligible/board certified in child or adolescent psychiatry. The requirement for
the specified psychiatrist for an eligible recipient under age 12 and under 21
years of age may be waived when all of the following conditions are met:
(1) the need for admission is urgent or
emergent, and transfer or referral to another provider poses an unacceptable
risk for adverse patient outcomes; and
(2) at the time of admission, a board
eligible/ board certified psychiatrist, or in the case of an eligible recipient
under 12 years of age, a child psychiatrist is not accessible in the community
in which the facility is located; and
(3) another facility which is able to furnish
a board eligible/board certified psychiatrist, or in the case of an eligible
recipient under 12 years of age, a child psychiatrist, is not available or
accessible in the community; and
(4) the admission is for stabilization only
and transfer arrangements to the care of a board eligible/ board certified
psychiatrist, or in the case of an eligible recipient under 12 years of age, a
child psychiatrist is made as soon as possible with the understanding that if
the eligible recipient needs to transfer to another facility, the actual
transfer will occur as soon as the eligible recipient is stable for transfer,
in accordance with professional standards.
K. Reimbursement for inpatient services: MAD
reimburses for inpatient hospital services using different methodologies. See
8.311.3 NMAC, Methods and Standards for Establishing Payment
Rates-Inpatient Hospital Services.
(1) All services or supplies furnished during
the hospital stay are reimbursed by the hospital payment amount and no other
provider may bill for services or supplies; an exception to this general rule
applies to durable medical equipment delivered for discharge and ambulance
transportation.
(2) A physician's
services are not reimbursed to a hospital under hospital services regulations,
but may be payable as a professional component of a service. See 8.310.2 NMAC,
Medical Services Providers, for information on the
professional component of services.
(3) Transportation services are billed as
part of a hospital claim if the hospital is DRG reimbursed and transportation
is necessary during the inpatient stay.
(a)
Transportation is included in a DRG payment when an eligible recipient is
transported to a different facility for procedure(s) not available at the
hospital where the eligible recipient is a patient.
(b) Exceptions are considered for air
ambulance services operated by a facility when air transportation constitutes
an integral part of the medical services furnished by the facility. See 8.324.7
NMAC, Transportation Services.
L. Reimbursement limitations for capital
costs: Reimbursement for capital costs follows the guidelines set forth in
HIM-15. See P.L. 97-248 (TEFRA). In addition, MAD applies the following
restrictions for new construction:
(1) The
total basis of depreciable assets does not exceed the median cost of
constructing a hospital as listed in an index acceptable to MAD, adjusted for
New Mexico costs and for inflation in the construction industry from the date
of publication to the date the provider is expected to become a MAD
provider.
(2) The cost of
construction is expected to include only the cost of buildings and fixed
equipment.
(3) A reasonable value
of land and major movable equipment is added to obtain the value of the entire
facility.
