Sec. 10.09.92.06. Utilization Review

A. Elective Inpatient Preauthorization Reviews.

(1) The hospital shall only request preauthorization for inpatient stays when such services:

(a) Cannot be provided on an outpatient basis; or

(b) Can only be provided in a facility that is licensed as an acute hospital.

(2) The hospital shall obtain preauthorization for elective inpatient admissions from the Department or its designee, before the participant is admitted, by providing the following information including, but not limited to:

(a) Participant’s medical history and physical; and

(b) Sufficient clinical information or documentation that supports the medical necessity of the acute inpatient admission.

B. Concurrent Reviews.

(1) As long as the participant remains hospitalized, the Department or its designee shall perform concurrent reviews based on the participant’s diagnosis and medical condition.

(2) For emergency inpatient admissions that exceed more than 24 hours, the concurrent review process shall be initiated by the hospital within the first 48 hours of the admission, or by the next business day.

(3) For elective inpatient admissions, the hospital shall initiate the concurrent review process before the termination of days previously certified by the Department or its designee.

(4) The hospital shall forward sufficient clinical documentation to the Department or its designee that supports the need for continuing acute care. Documentation submitted shall include, but is not limited to:

(a) Current medical health status;

(b) Treatment received to date; and

(c) A proposed treatment plan for the continued stay.

C. Retrospective Reviews.

(1) The hospital shall request that the Department or its designee perform a retrospective review of an inpatient admission after the participant is discharged, to determine the medical necessity of the admission and stay.

(2) The hospital shall provide the following to the Department or its designee when requesting a retrospective review following discharge from an acute hospital. Documentation submitted shall include, but is not limited to:

(a) The participant’s complete medical record;

(b) The principal, secondary, and tertiary diagnoses; and

(c) All surgical procedure codes.

D. Reviews for Nonqualified Aliens. The Department or its designee reviews the admission and discharge summary of an emergency inpatient admission for a nonqualified alien to determine whether the inpatient hospital stay meets the emergent condition criteria as defined in COMAR 10.09.24.05-2A.

E. Reviews for Behavioral Health. The hospital shall contact the behavioral health ASO to request an authorization for all inpatient admissions that are described in COMAR 10.09.70.02D and F.