Sec. 10.09.93.08. Utilization Review

A. Admission and Prior Approval.

(1) For participants and individuals who have applied for Medical Assistance, the provider shall request a determination from the Department or its designee at the time of admission, or at the time of application for Medical Assistance, that the individual meets the medical eligibility criteria set forth in Regulation .07A of this chapter.

(2) For a participant to be preauthorized for services in a brain injury community integration program, a provider that meets the requirements of Regulation .04 of this chapter shall request a determination from the Department or its designee that the participant meets the criteria set forth in Regulation .07B of this chapter.

(3) If the provider obtains the determination set forth in §A(1) or (2) of this regulation after admission, the eligibility determination shall be effective on the date that the determination was requested.

B. Concurrent Review.

(1) On a monthly basis, the provider shall notify the Department or its designee of all persons who have:

(a) Received an initial determination of medical eligibility for chronic hospital services;

(b) Been determined to continue to meet medical eligibility criteria for chronic hospital services;

(c) Been discharged; or

(d) Been determined to no longer be medically eligible.

(2) Concurrent review shall be conducted every 14 days as long as the participant remains hospitalized to ensure the medical necessity of the participant’s inpatient stay.

(3) The Department or its designee may conduct on-site reviews.

C. Administrative Days.

(1) To be paid for administrative days, the provider shall document, in a form designated by the Department, information which satisfies the conditions listed below:

(a) The participant who was initially eligible has been determined to no longer require chronic hospital services, and the provider has:

(i) Received a determination from the Department or its designee that the participant requires the level of service provided by a nursing facility but an appropriate facility is not available;

(ii) Established a plan for discharge during the period of administrative days, is actively pursuing placement at an appropriate level of care for the participant, and has documented this activity in the participant’s record; and

(iii) Submitted documentation to the Department or its designee that placement activity was conducted no fewer than 3 days per week during the period for which payment is requested for administrative days; or

(b) The participant is no longer medically eligible to receive chronic hospital services but cannot be moved, and the following conditions are met:

(i) The medical reason the participant cannot be moved is documented by the attending physician in the participant’s medical record;

(ii) The attending physician reevaluates the medical cause of the participant’s inability to be moved at least once every 7 days; and

(iii) The provider documents the active treatments used to resolve the medical cause of the participant’s inability to be moved;

(2) To receive reimbursement for administrative days, the provider shall document that it has met the conditions of §C(1) of this regulation, at least every 14 days.

(3) Documentation shall be submitted to the Department or its designee no later than 3 business days following the end of the 14-day period.