Sec. 10.09.94.06. Utilization Review

A. The Department or its designee shall conduct utilization review to determine that special pediatric hospital admissions and outpatient services are authorized only when medically necessary.

B. Review Procedure.

(1) For all admissions, the special pediatric hospital shall provide:

(a) The elements of a participant’s medical record specified by the Department or its designee for preadmission review, and request to certify the participant’s admission; and

(b) Sufficient clinical information or documentation to the Department or its designee that supports the need for admission to a special pediatric hospital including, but not limited to:

(i) Current medical health status;

(ii) Treatment received to date;

(iii) Proposed treatment plan for requested admission; and

(iv) Expected length of stay.

(2) Admission for inpatient services may be authorized only when these services cannot be provided:

(a) On an outpatient basis; or

(b) In a facility that is licensed to provide a more appropriate level of care to the participant.

(3) Concurrent review shall be conducted as long as the participant remains hospitalized, based on the participant’s diagnosis and condition, to ensure the medical necessity of the participant’s inpatient stay, at the following intervals:

(a) After an initially authorized 14-day stay, or at the end of the expected length of stay identified at admission, whichever comes first; and

(b) Every 14 days following the initial concurrent review, in a form and including clinical documentation as specified by the Department or its designee.

(4) The Department or its designee may conduct on-site reviews after an initially authorized period of 30 days, and every 30 days thereafter until discharge.

(5) An elective inpatient hospital admission requires preadmission authorization by the Department or its designee.

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 has been determined to no longer require special pediatric 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 in a lower-acuity 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 special pediatric 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.