Ala. Admin. Code r. 560-X-46-.08

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

Section 560-X-46-.08 - Admission And Periodic Review

(1) The Medicaid Medical and Quality Review Unit or designee will perform admission review of all Medicaid admissions to ensure the necessity and appropriateness of the admission and that a physician has certified on the date of admission, the need for swing bed care. Medicaid or its designee will certify the level of care required by the patient at the time of admission by utilizing Form 199.

(2) For applications which are not approved by the Medical and Quality Review Unit or its designee, a Medical Director, will review and either approve or deny the medical eligibility.

(3) Recipients must meet Skilled Nursing Facility (SNF) medical and financial requirements for swing bed admissions just as they are required for SNF admissions. Refer to Chapter 10 and Chapter 25.

(4) For recipients who receive retroactive Medicaid eligibility while utilizing swing bed services, the hospital should furnish all doctors' orders, progress and nurses' notes for the time in question to Medicaid's fiscal agent.

(5) Medical approvals may be issued by the Medicaid Medical and Quality Review Unit or designee if the information provided to Medicaid documents the need for SNF care and the recipient meets criteria set forth in Rule 560-X-10-.10 for SNF care.

(a) The admission application packet must be sent to the Medicaid Medical and Quality Review unit or designee within 60 days from the date Medicaid coverage is sought and consist of: a fully completed Medicaid Status Notification Form 199 including all documentation certified by the applicant's attending physician to support the need for nursing home level of care. Refer to Rule 560-X-10-.10 and .13, for in-depth information.

(b) Once the Form 199 has been reviewed and approved medically, the facility is notified by a letter advising that the patient is medically eligible for swing bed services.

(6) Continued stay reviews are required to assure the necessity and appropriateness of skilled care and effectiveness of discharge planning. Recertification of SNF patients is required 30, 60, and 90 days after admission and then every 60 days thereafter. Physicians must state "I certify" and specify that the patient requires skilled care for continued stay in the facility. Facilities must have written policies and procedures for recertification.

(7) Reimbursement requires a 3-day qualifying stay in any acute care hospital prior to admission to a swing bed in any hospital. The swing-bed stay must fall within the same period of illness as the qualifying stay.

Ala. Admin. Code r. 560-X-46-.08

Emergency rule effective March 30, 1989. Permanent rule effective July 13, 1989. Amended: Filed October 6, 1999; effective November 10, 1999. Amended: Filed November 12, 2013; effective December 17, 2013.

Author: Jerri Jackson, Associate Director, Institutional Services Unit.

Statutory Authority: Title XIX, Social Security Act; State Plan, Attachment 3.1-A, 4.19-D; 42 CFR §§ 435.1009, 456.1, 435.911, 409, Subpart D.