Current through Register Vol. 24-18, September 15, 2024
(1)
The medicaid agency requires prior authorization for acute PM&R services.
The acute PM&R provider of services must obtain prior authorization:
(a) Before admitting a client to the
rehabilitation unit; and
(b) For an
extension of stay before the client's current authorized period of stay
expires.
(2) For an
initial admit:
(a) A client must:
(i) Be eligible under one of the programs
listed in WAC
182-550-2521, subject to the
restrictions and limitations listed in that section;
(ii) Require acute PM&R services as
determined in WAC
182-550-2551;
(iii) Be medically stable and show evidence
of physical and cognitive readiness to participate in the rehabilitation
program; and
(iv) Be willing and
capable to participate at least three hours per day, seven days per week, in
acute PM&R activities.
(b) The acute PM&R provider of services
must:
(i) Submit a request for prior
authorization to the agency's clinical consultation team by fax, electronic
mail, or telephone as published in the agency's acute PM&R billing
instructions; and
(ii) Include
sufficient medical information to justify that:
(A) Acute PM&R treatment would
effectively enable the client to obtain a greater degree of self-care or
independence;
(B) The client's
medical condition requires that intensive twenty-four-hour inpatient
comprehensive acute PM&R services be provided in an agency-approved acute
PM&R facility; and
(C) The
client suffers from severe disabilities including, but not limited to,
neurological or cognitive deficits.
(3) For an extension of stay:
(a) A client must meet the conditions listed
in subsection (2)(a) of this section and have observable and significant
improvement; and
(b) The acute
PM&R provider of services must:
(i) Submit
a request for the extension of stay to the agency clinical consultation team by
fax, electronic mail, or telephone as published in the agency's acute PM&R
billing instructions; and
(ii)
Include sufficient medical information to justify the extension and include
documentation that the client's condition has observably and significantly
improved.
(4)
If the agency denies the request for an extension of stay, the client must be
transferred to an appropriate lower level of care as described in WAC
182-550-2501(3).
(5) The agency's clinical consultation team
approves or denies authorization for acute PM&R services for initial stays
or extensions of stay based on individual circumstances and the medical
information received. The agency notifies the client and the acute PM&R
provider of a decision.
(a) If the agency
approves the request for authorization, the notification letter includes:
(i) The number of days requested;
(ii) The allowed dates of service;
(iii) An agency-assigned authorization
number;
(iv) Applicable limitations
to the authorized services; and
(v)
The agency's process to request additional services.
(b) If the agency denies the request for
authorization, the notification letter includes:
(i) The number of days requested;
(ii) The reason for the denial;
(iii) Alternative services available for the
client; and
(iv) The client's
right to request a fair hearing. (See subsection (7) of this
section.)
(6)
A hospital or other facility intending to transfer a client to an
agency-approved acute PM&R hospital or an agency-approved acute PM&R
hospital requesting an extension of stay for a client must:
(a) Discuss the agency's authorization
decision with the client or the client's legal representative; and
(b) Document in the client's medical record
that the agency's decision was discussed with the client or the client's legal
representative.
(7) A
client who does not agree with a decision regarding acute PM&R services has
a right to a fair hearing under chapter 182-526 WAC. After receiving a request
for a fair hearing, the agency may request additional information from the
client and the facility, or both. After the agency reviews the available
information, the result may be:
(a) A
reversal of the initial agency decision;
(b) Resolution of the client's issue(s);
or
(c) A fair hearing conducted per
chapter 182-526 WAC.
(8)
The agency may authorize administrative days for a client who:
(a) Does not meet requirements described in
subsection (3) of this section; or
(b) Is waiting for a discharge destination or
a discharge plan.
(9)
The agency does not authorize acute PM&R services for a client who:
(a) Is deconditioned by a medical illness or
by surgery; or
(b) Has loss of
function primarily as a result of a psychiatric condition; or
(c) Has had a recent surgery and has no
complicating neurological deficits. Examples of surgeries that do not qualify a
client for inpatient acute PM&R services without extenuating circumstances
are:
(i) Single amputation;
(ii) Single extremity surgery; and
(iii) Spine surgery.
11-14-075, recodified as §182-550-2561, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090 and
74.09.500. 07-12-039, §
388-550-2561, filed 5/30/07, effective 8/1/07. Statutory Authority:
RCW
74.08.090,
74.09.520 and
42 C.F.R.
482.56. 03-06-047, § 388-550-2561, filed
2/28/03, effective 3/31/03. Statutory Authority:
RCW
74.08.090 and
74.09.520. 99-17-111, §
388-550-2561, filed 8/18/99, effective
9/18/99.
