(a) The hospital or its designee shall notify the Department at least three (3) working days prior to the proposed admission and provide the information required by Sections 9(b) and (c) of this Chapter.
(b) Notice from the hospital or its designee shall be given in writing as required by the Department.
(c) Upon receipt of the information required by Sections 9(b) and (c) of this Chapter, a clinical evaluator shall review the information and determine whether the admission meets the medical necessity criteria. - (i) If the clinical evaluator determines the admission meets the medical necessity criteria, the Department shall issue a Prior Authorization (PA) number, which shall be communicated by an admission certification letter to the attending physician or the hospital as required by the Department, by the end of the next working day after the determination.
- (ii) An inpatient hospital service which is not a covered service shall not receive a PA number.
- (iii) If the clinical evaluator is unable to determine that the admission meets the medical necessity criteria, the evaluator shall refer the matter to a physician adviser.
(d) If the physician adviser determines that the admission meets the medical necessity criteria, the Department shall issue a PA number. In determining whether the admission is medically necessary, the physician adviser may consult with the attending physician or other physician advisers.
(e) The physician advisers determination shall be communicated to the attending physician or, in the case of a continued stay review, the hospital, in writing as required by the Department, by the end of the next working day after the referral to the physician adviser. - (i) If the admission is certified, the Department shall issue an admission certification letter and PA number to the attending physician and the hospital, in writing as required by the Department.
- (ii) If the admission is not certified, the Department shall send written denial of admission certification to the attending physician and the hospital by the end of the next working day after the physician advisers decision.
- (iii) Appeal of denial. The attending physician or the hospital may appeal the denial of admission certification by submitting a written request to the Departments designee within twenty (20) working days after the date of receipt of the notice of denial. The denial shall be reviewed within three (3) working days of the Departments receipt, by a physician adviser who has not previously been consulted about the admission. The physician advisor may review the medical record, consult with the clinical evaluator and the physician adviser who were previously involved in the case or another physician adviser, and request other information from the attending physician and the hospital.
- (A) If the appeal results in admission certification, the Department shall issue an admission certification letter and PA number to the attending physician and the hospital.
- (B) If the appeal results in upholding the denial of admission certification, the Department shall send written denial to the attending physician and hospital. Either the attending physician or the hospital may ask for a hearing on the denial pursuant to Chapter 4.
(f) The issuance of an admission certification and PA number is not a guarantee of Medicaid reimbursement or a guarantee that the individual is a client at the time of admission. Reimbursement is subject to benefit coverage changes or aging out. Admissions are subject to continued stay and/or post-payment review pursuant to Section 13 of this Chapter. An admission certification and PA number may be withdrawn as a result of such reviews.
(g) Continued stay review of Non-emergent Admissions. - (i) Required continued stay review. A hospital shall request continued stay review of any client who is expected to remain hospitalized after the period, if any, specified in the admission certification.
- (ii) Discretionary continued stay review. The Department may conduct a continued stay review of any non-emergent admission which results in the provision of inpatient hospital services to a client.
- (iii) Medicaid payments. There shall be no Medicaid payments to any provider of inpatient hospital services except to the extent that the continued stay review results in admission certification.