Current through September 21, 2024
(a) The hospital or
its designee shall notify the Department at least three (3) working days prior
to the proposed admission and provide the information required by Sections 9(b)
and (c) of this Chapter.
(b) Notice
from the hospital or its designee shall be given in writing as required by the
Department.
(c) Upon receipt of the
information required by Sections 9(b) and (c) of this Chapter, a clinical
evaluator shall review the information and determine whether the admission
meets the medical necessity criteria.
(i) If
the clinical evaluator determines the admission meets the medical necessity
criteria, the Department shall issue a Prior Authorization (PA) number, which
shall be communicated by an admission certification letter to the attending
physician or the hospital as required by the Department, by the end of the next
working day after the determination.
(ii) An inpatient hospital service which is
not a covered service shall not receive a PA number.
(iii) If the clinical evaluator is unable to
determine that the admission meets the medical necessity criteria, the
evaluator shall refer the matter to a physician adviser.
(d) If the physician adviser determines that
the admission meets the medical necessity criteria, the Department shall issue
a PA number. In determining whether the admission is medically necessary, the
physician adviser may consult with the attending physician or other physician
advisers.
(e) The physician
advisers determination shall be communicated to the attending physician or, in
the case of a continued stay review, the hospital, in writing as required by
the Department, by the end of the next working day after the referral to the
physician adviser.
(i) If the admission is
certified, the Department shall issue an admission certification letter and PA
number to the attending physician and the hospital, in writing as required by
the Department.
(ii) If the
admission is not certified, the Department shall send written denial of
admission certification to the attending physician and the hospital by the end
of the next working day after the physician advisers decision.
(iii) Appeal of denial. The attending
physician or the hospital may appeal the denial of admission certification by
submitting a written request to the Departments designee within twenty (20)
working days after the date of receipt of the notice of denial. The denial
shall be reviewed within three (3) working days of the Departments receipt, by
a physician adviser who has not previously been consulted about the admission.
The physician advisor may review the medical record, consult with the clinical
evaluator and the physician adviser who were previously involved in the case or
another physician adviser, and request other information from the attending
physician and the hospital.
(A) If the appeal
results in admission certification, the Department shall issue an admission
certification letter and PA number to the attending physician and the
hospital.
(B) If the appeal results
in upholding the denial of admission certification, the Department shall send
written denial to the attending physician and hospital. Either the attending
physician or the hospital may ask for a hearing on the denial pursuant to
Chapter 4.
(f) The issuance of an admission
certification and PA number is not a guarantee of Medicaid reimbursement or a
guarantee that the individual is a client at the time of admission.
Reimbursement is subject to benefit coverage changes or aging out. Admissions
are subject to continued stay and/or post-payment review pursuant to Section 13
of this Chapter. An admission certification and PA number may be withdrawn as a
result of such reviews.
(g)
Continued stay review of Non-emergent Admissions.
(i) Required continued stay review. A
hospital shall request continued stay review of any client who is expected to
remain hospitalized after the period, if any, specified in the admission
certification.
(ii) Discretionary
continued stay review. The Department may conduct a continued stay review of
any non-emergent admission which results in the provision of inpatient hospital
services to a client.
(iii)
Medicaid payments. There shall be no Medicaid payments to any provider of
inpatient hospital services except to the extent that the continued stay review
results in admission certification.
