Ala. Admin. Code r. 480-5-5-.10

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.10 - Continued Stay Review Procedures

(1) The RUE or employer/agent is responsible for initiating the medical necessity review for continued hospitalization before the initial assigned length of stay expires. The responsibility to request an extension may be delegated to the hospital, if requested by the hospital and agreed to in writing by the RUE or employer/agent.

(2) Continued stay review shall include telephone/on-site discussions/review with the hospital, or with the physician for the information required. All pertinent information necessary to determine if continued hospitalization is medically necessary shall be gathered (i.e., treatment, diagnosis, current medications and methods of administration used, frequency, lab values, and results of diagnostic tests).

(a) If continued stay is appropriate, additional days shall be based upon the medical condition of the patient and the treatment plan. This process shall continue until the patient is discharged.

(b) If continued stay is not medically necessary or appropriate, based upon documentation reviewed, the reviewing physician, Second Level Clinical Review as defined in Rule 480-5-5-.06(3), shall issue a denial to the physician and hospital the same day of the review.

(3) The RUE or employer/agent shall use generally accepted criteria to assess the need for continued stay in the hospital. Physicians, board certified in the same or similar specialty as defined in Rule 480-5-5-.06(4), Peer Clinical Review, (Third Level Clinical Review) or the specialty that normally treats the patient's condition shall review all adverse decisions and make the final decisions on all denials of certification. The appeals process Peer Clinical Review (Third Level Clinical Review) in Rule 480-5-5-.07 and/or 480-5-5-.23, may be followed in, cases of denied services disputes.

(4) The continued stay review process shall be used to identify and refer cases, for discharge planning pursuant to Rule 480-5-5-.24.

(5) The review shall include telephone or facsimile notification of the decision to the physician, hospital or other providers, and written notification of adverse decisions.

(6) The RUE or employer/agent shall maintain appropriate internal documentation to verify the process and the decision, for claims processing, reporting, and audit purposes.

(7) The RUE or employer/agent shall announce the results of the review process to the admitting/treating physician and the hospital in writing. The denial letter shall contain the following elements: employee's name, identifying number, and address; date of service; date of injury; name of provider and facility; pre-certification number; reason for denial and the appeals process.

Ala. Admin. Code r. 480-5-5-.10

New Rule: Filed August 9, 1996; effective September 13, 1996. Amended: Filed December 5, 2008; effective January 9, 2009.

Author: Workers' Compensation Medical Services Board

Statutory Authority:Code of Ala. 1975, § 25-5-293.