Current through Register Vol. 41, No. 3, September 23, 2024
A. Psychiatric
services in freestanding psychiatric hospitals shall only be covered for
eligible persons younger than 21 years of age and older than 64 years of
age.
B. DMAS shall monitor,
consistent with state law, the utilization of all inpatient freestanding
psychiatric hospital services. All inpatient hospital stays shall be
preauthorized prior to reimbursement for these services. Services rendered
without such prior authorization shall not be covered.
C. All Medicaid services are subject to
utilization review and audit. Absence of any of the required documentation may
result in denial or retraction of any reimbursement. In each case for which
payment for freestanding psychiatric hospital services is made under the State
Plan:
1. A physician must certify at the time
of admission, or at the time the hospital is notified of an individual's
retroactive eligibility status, that the individual requires or required
inpatient services in a freestanding psychiatric hospital consistent with
42 CFR
456.160.
2. The physician, physician assistant, or
nurse practitioner acting within the scope of practice as defined by state law
and under the supervision of a physician, must recertify at least every 60 days
that the individual continues to require inpatient services in a psychiatric
hospital.
3. Before admission to a
freestanding psychiatric hospital or before authorization for payment, the
attending physician or staff physician must perform a medical evaluation of the
individual and appropriate professional personnel must make a psychiatric and
social evaluation as cited in
42 CFR
456.170.
4. Before admission to a freestanding
psychiatric hospital or before authorization for payment, the attending
physician or staff physician must establish a written plan of care for each
recipient patient as cited in
42 CFR
441.155 and
456.180. The plan shall also
include a list of services provided under written contractual arrangement with
the freestanding psychiatric hospital (see
12VAC30-50-130) that will be
furnished to the patient through the freestanding psychiatric hospital's
referral to an employed or contracted provider, including the prescribed
frequency of treatment and the circumstances under which such treatment shall
be sought.
D. If the
eligible individual is 21 years of age or older, then in order to qualify for
Medicaid payment for this service, the individual must be at least 65 years of
age.
E. If younger than 21 years of
age, it shall be documented that the individual requiring admission to a
freestanding psychiatric hospital is younger than 21 years of age, that
treatment is medically necessary, and that the necessity was identified as a
result of an early and periodic screening, diagnosis, and treatment (EPSDT)
screening. Required patient documentation shall include the following:
1. An EPSDT physician's screening report
showing the identification of the need for further psychiatric evaluation and
possible treatment.
2. A diagnostic
evaluation documenting a current (active) psychiatric disorder based on
nationally recognized criteria that supports the treatment recommended. The
diagnostic evaluation must be completed prior to admission.
3. For admission to a freestanding
psychiatric hospital for psychiatric services resulting from an EPSDT
screening, a certification of the need for services as defined in
42 CFR
441.152 by an interdisciplinary team meeting
the requirements of 42 CFR
441.153 or
441.156 and the Psychiatric
Treatment of Minors Act (§
16.1-335 et seq. of the Code of
Virginia).
F. If a
Medicaid eligible individual is admitted in an emergency to a freestanding
psychiatric hospital on a Saturday, Sunday, holiday, or after normal working
hours, it shall be the provider's responsibility to obtain the required
authorization on the next work day following such an admission.
G. The absence of any of the required
documentation described in this subsection shall result in a DMAS denial of the
requested preauthorization and coverage of subsequent
hospitalization.
H. To determine
that the DMAS-enrolled mental hospital providers are in compliance with the
regulations governing mental hospital utilization control found in
42 CFR
456.150, an annual audit will be conducted of
each enrolled hospital. This audit may be performed either on site or as a desk
audit. The hospital shall make all requested records available and shall
provide an appropriate place for the auditors to conduct such review if done on
site. The audits shall consist of review of the following:
1. Copy of the mental hospital's Utilization
Management Plan to determine compliance with the regulations found in
42 CFR
456.200 through
456.245.
2. List of current Utilization Management
Committee members and physician advisors to determine that the committee's
composition is as prescribed in
42 CFR
456.205 and
456.206.
3. Verification of Utilization Management
Committee meetings, including dates and list of attendees, to determine that
the committee is meeting according to the committee's utilization management
meeting requirements.
4. One
completed Medical Care Evaluation Study to include objectives of the study,
analysis of the results, and actions taken or recommendations made to determine
compliance with 42 CFR
456.241 through
456.245.
5. Topic of one ongoing Medical Care
Evaluation Study to determine the hospital is in compliance with
42 CFR
456.245.
6. From a list of randomly selected paid
claims, the freestanding psychiatric hospital must provide a copy of the
certification for services, a copy of the physician admission certification, a
copy of the required medical, psychiatric, and social evaluations and the
written plan of care for each selected stay to determine the hospital's
compliance with §§
16.1-335 through
16.1-348 of the Code of Virginia
and 42 CFR
441.152,
456.160,
456.170,
456.180, and
456.181. If any of the required
documentation does not support the admission and continued stay, reimbursement
may be retracted.
I. The
freestanding psychiatric hospital shall not receive a per diem reimbursement
for any day that:
1. The initial or
comprehensive written plan of care fails to include, within three business days
of the initiation of the service provided under arrangement, all services that
the individual needs while at the freestanding psychiatric hospital and that
will be furnished to the individual through the freestanding psychiatric
hospital's referral to an employed or contracted provider of services under
arrangement;
2. The comprehensive
plan of care fails to include, within three business days of the initiation of
the service, the prescribed frequency of such service or includes a frequency
that was exceeded;
3. The
comprehensive plan of care fails to list the circumstances under which the
service provided under arrangement shall be sought;
4. The referral to the service provided under
arrangement was not present in the patient's freestanding psychiatric hospital
record;
5. The service provided
under arrangement was not supported in that provider's records by a documented
referral from the freestanding psychiatric hospital;
6. The medical records from the provider of
services under arrangement (i.e., admission and discharge documents, treatment
plans, progress notes, treatment summaries, and documentation of medical
results and findings) (i) were not present in the patient's freestanding
psychiatric hospital record or had not been requested in writing by the
freestanding psychiatric hospital within seven days of completion of the
service or services provided under arrangement or (ii) had been requested in
writing within seven days of completion of the service or services, but had not
been received within 30 days of the request, and had not been re-requested;
or
7. The freestanding psychiatric
hospital did not have a fully executed contract or an employee relationship
with the provider of services under arrangement in advance of the provision of
such services. For emergency services, the freestanding psychiatric hospital
shall have a fully executed contract with the emergency services hospital
provider prior to submission of the ancillary provider's claim for
payment.
J. The provider
of services under arrangement shall be required to reimburse DMAS for the cost
of any such service billed prior to receiving a referral from the freestanding
psychiatric hospital or in excess of the amounts in the referral.
K. The hospitals may appeal in accordance
with the Administrative Process Act (§
2.2-4000 et seq. of the Code of
Virginia) any adverse decision resulting from such audits that results in
retraction of payment. The appeal must be requested pursuant to the
requirements of
12VAC30-20-500 through
12VAC30-20-570.
Statutory Authority: §§
32.1-324 and
32.1-325 of the Code of
Virginia.
