Sec. 10.09.95.06. Utilization Review Requirements

A. Elective Inpatient Preauthorization Reviews.

(1) The special psychiatric 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 a special psychiatric hospital.

(2) The special psychiatric 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 inpatient admission.

B. Concurrent Review Process.

(1) The concurrent review process shall be initiated by the hospital.

(2) If the participant remains hospitalized, additional days shall be certified by the Department or its designee before the termination of the previously certified days.

(3) The special psychiatric hospital shall forward sufficient clinical information or documentation to the Department or its designee that supports the need for continuing care. Information submitted shall include:

(a) Current health status;

(b) Treatment received to date;

(c) Proposed treatment plan for continued stay; and

(d) Discharge planning.

C. Retrospective Reviews.

(1) The special psychiatric 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.

(2) The special psychiatric hospital shall provide the following to the Department or its designee when requesting a retrospective review following discharge from a special psychiatric 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 relevant 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 special psychiatric hospital stay meets the emergent condition criteria as defined in COMAR 10.09.24.05-2A.