Current through Reg. 49, No. 38; September 20, 2024
(a)
Purpose. A recipient must have a determination of medical necessity for nursing
facility care to participate in the Texas Medicaid Nursing Facility Program.
(1) The state Medicaid claims administrator
makes a medical necessity determination by evaluating a recipient's medical and
nursing needs based on the MDS assessment required by DADS.
(2) A recipient must have a determination of
medical necessity for nursing facility care before the nursing facility can be
paid for services, except as provided in § 554.2413 of this subchapter
(relating to Determination of Payment Rate Based on the MDS Assessment
Submission) and § 554.2611 of this chapter (relating to Retroactive Vendor
Payment).
(b) Admission
MDS assessment review.
(1) The admission MDS
assessment review process is initiated when the state Medicaid claims
administrator receives an MDS assessment and the Long-Term Care Medicaid
Information Section, in accordance with § 554.2413 of this subchapter,
indicating that a Medicaid applicant or recipient is requesting vendor payment
for care in a contracted nursing facility. A registered nurse must sign and
certify that the MDS assessment is completed in accordance with § 554.801
of this chapter (relating to Resident Assessment).
(2) The admission MDS assessment review
determines medical necessity and establishes the authorization for payment of a
calculated RUG rate.
(c)
Role of the state Medicaid claims administrator. The state Medicaid claims
administrator reviews all MDS assessments, including significant change in
status assessments, modifications, and significant corrections, and approves or
denies medical necessity in accordance with § 554.2401 of this subchapter
(relating to General Qualifications for Medical Necessity
Determinations).
(d) Effective
period.
(1) A determination of medical
necessity based on the admission MDS assessment review remains in effect for
the time period determined by the federal MDS submission schedule.
(2) If a nursing facility submits a
recipient's MDS assessment after the due date established by the federal MDS
submission schedule, the recipient's medical necessity remains in effect for
the period between the due date and the date the state Medicaid claims
administrator received the MDS assessment.
(3) If a nursing facility submits a
recipient's MDS assessment after the due date established by the federal MDS
submission schedule and, after reviewing the MDS assessment, the state Medicaid
claims administrator determines that the recipient does not meet the criteria
for medical necessity, the effective date of the denial of medical necessity is
the date the state Medicaid claims administrator received the MDS assessment. A
denial of medical necessity is conducted in accordance with § 554.2407 of
this subchapter (relating to Denied Medical Necessity).
(e) Permanent medical necessity.
(1) A recipient's permanent medical necessity
status is established on the completion date of any MDS assessment approved for
medical necessity no less than 184 calendar days after the recipient's
admission to the Texas Medicaid Nursing Facility Program.
(2) A nursing facility must submit a
recipient's MDS assessment in compliance with the federal MDS submission
schedule even after the recipient achieves permanent medical necessity
status.
(3) A recipient's permanent
medical necessity status moves with the recipient, unless the recipient is
discharged to home for more than 30 days.
(4) If a recipient who has permanent medical
necessity status transfers to another Medicaid-certified nursing facility, the
nursing facility to which the recipient transfers must complete a new MDS
assessment in compliance with the federal MDS submission schedule.
(f) Insufficient information. If
an MDS assessment does not have sufficient information for the state Medicaid
claims administrator to make a medical necessity determination, the MDS
assessment is put in suspense for 21 days with a message from the state
Medicaid claims administrator informing the nursing facility that the MDS
assessment has been put in suspense for 21 days. Unless the nursing facility
provides sufficient information on the MDS assessment to determine medical
necessity within 21 days, medical necessity is denied.
