Ala. Admin. Code r. 560-X-41-.04

Current through Register Vol. 43, No. 02, November 27, 2024

Section 560-X-41-.04 - Certification Of Need For Inpatient Hospital Services

(1) Certification of need for inpatient hospital services is a determination which is made by the certifying team as specified in (4) below regarding the Medicaid recipient's treatment needs for admission to the facility.

(2) The appropriate team must certify that:

(a) Ambulatory care resources available in the community do not meet the treatment needs of the recipient;

(b) Proper treatment of the recipient's psychiatric condition requires services on an inpatient basis under the direction of a physician; and

(c) The services can reasonably be expected to improve the recipient's condition or prevent further regression so that the services will no longer be needed.

(3) The appropriate certifying team must complete the PSY-2 form which is the certification of need for inpatient hospital services.

(4) Certification of need for services must be made by teams specified as follows:

(a) For an individual who is a Medicaid recipient and is a nonemergency admission to the facility the certification of need for services must be made prior to the admission. If the certification is completed subsequent to admission, payment cannot be made for the period prior to the date the certification is completed. Certification must be made by an independent team that:

1. Includes a physician;

2. Has competence in diagnosis and treatment of mental illness, preferably in child psychiatry; and

3. Has knowledge of the individual's situation.

(b) Certification of need for services may be made by the team as specified in Rule 560-X-41-.04(4)(a) provided the team is not:

1. Employed and reimbursed by the facility, or

2. In partnership with the attending physician, or

3. On the treatment team caring for the patient.

(c) For an individual who applies for Medicaid while in the facility, the certification of need for services must:

1. Be made by the team responsible for the plan of care as specified in Rule 560-X-41-.06(3), and

2. Cover any period before application for which claims are made.

3. If the certification is completed subsequent to the filing of the application, payment cannot be made for the period prior to the date the certification is completed.

(d) For emergency admissions the certification of need for services must be made by the team responsible for the plan of care as specified in Rule 560-X-41-.06(3) within 14 working days after admission.

(5) An emergency admission is described as a situation where the patient's condition is such that prompt provision of care is necessary to prevent the death or serious impairment of the health of the patient or others due to the individual's psychiatric condition. The presence of a court order does not in itself justify characterizing an admission as an emergency.

Author: Lynn Sharp, Associate Director, Institutional Services

Ala. Admin. Code r. 560-X-41-.04

Rule effective October 1, 1988. Amended effective September 13, 1989. Emergency rule effective August 21, 1991. Amended effective November 13, 1991. Amended: Filed November 8, 2001; effective December 13, 2001.

Statutory Authority: State Plan, Attachment 3.1-A, pp. 7, 7.16; 42 C.F.R. §§441, Subpart D.