Md. Code Regs. 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:
(c)
(b) Sufficient clinical information or documentation
that supports the medical necessity of the inpatient admission.
(a) Participant's medical history and
physical;
(b) Doctor's progress notes;
and
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.
Notes
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