Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
Subchapter Y - MEDICAL NECESSITY DETERMINATIONS
Section 554.2401 - General Qualifications for Medical Necessity Determinations
Universal Citation: 26 TX Admin Code ยง 554.2401
Current through Reg. 49, No. 38; September 20, 2024
Medical necessity is the prerequisite for participation in the Medicaid (Title XIX) Long-term Care program. This section contains the general qualifications for a medical necessity determination. To verify that medical necessity exists, an individual must meet the conditions described in paragraphs (1) and (2) of this section.
(1) The individual must demonstrate a medical condition that:
(A) is of sufficient
seriousness that the individual's needs exceed the routine care which may be
given by an untrained person; and
(B) requires licensed nurses' supervision,
assessment, planning, and intervention that are available only in an
institution.
(2) The individual must require medical or nursing services that:
(A) are ordered by a physician;
(B) are dependent upon the individual's
documented medical conditions;
(C)
require the skills of a registered or licensed vocational nurse;
(D) are provided either directly by or under
the supervision of a licensed nurse in an institutional setting; and
(E) are required on a regular
basis.
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