130 CMR 415.414 - Utilization Review

(A) All inpatient services must be provided in accordance with 130 CMR 450.204: Medical Necessity or 130 CMR 415.415, and are subject, among other things, to utilization review under 130 CMR 450.207: Utilization Management Program for Acute Inpatient Hospital through 450.209: Utilization Management: Prepayment Review for Acute Inpatient Hospitals and to requirements governing overpayments under 130 CMR 450.235(B): Overpayments and 450.237: Overpayments: Determination.

(B)

(1) The MassHealth agency (or its agent) will review inpatient services provided to members to determine the medical necessity, pursuant to 130 CMR 450.204: Medical Necessity, or administrative necessity and appropriateness, pursuant to 130 CMR 415.415, of such services. Any such review may be conducted prior to, concurrently, or retrospectively following the member's inpatient admission. Reviewers consider the medical-record documentation of clinical information available to the admitting provider at the time the decision to admit was made. Reviewers do not deny admissions based on what happened to the member after the admission. However, if an admission was not medically necessary at the time of the decision to admit, but the medical record indicates that an inpatient admission later became medically necessary, the admission will be approved as long as all other MassHealth requirements are met.

(2) If, pursuant to any review, the Division concludes that the inpatient admission was not medically or administratively necessary, the Division will deny payment for the inpatient admission.

(3) If the Division issues a denial notice for an acute inpatient hospital admission pursuant to 130 CMR 415.414 and 450.204: Medical Necessity as well as either 130 CMR 450.209: Utilization Management: Prepayment Review for Acute Inpatient Hospitals or 450.237: Overpayments: Determination, the hospital may rebill the claim as an outpatient service, as long as the Division has determined the service would have been appropriately provided in an outpatient setting. In order for the hospital to receive payment under 130 CMR 415.414(B)(3), the outpatient claim and a copy of the denial notice must be received by the Division within 90 days from the date of the denial notice and must comply with all applicable Division requirements.

(C) To support the medical necessity of an inpatient admission, the provider must adequately document in the member's medical record that a provider with applicable expertise expressly determined that the member required services involving a greater intensity of care than could be provided safely and effectively in an outpatient setting. Such a determination may take into account the amount of time the member is expected to require inpatient services, but must not be based solely on this factor. The decision to admit is a medical determination that is based on factors, including but not limited to the:

(1) member's medical history;

(2) member's current medical needs;

(3) severity of the signs and symptoms exhibited by the member;

(4) medical predictability of an adverse clinical event occurring with the member;

(5) results of outpatient diagnostic studies;

(6) types of facilities available to inpatients and outpatients; and

(7) MassHealth agency's Acute Inpatient Hospital Admission Guidelines in Appendix F of the Acute Inpatient Hospital Manual and in various appendices of other appropriate provider manuals. The MassHealth agency has developed such guidelines to help providers determine the medical necessity of an acute inpatient hospital admission. These guidelines indicate when there is generally no medical need for such an admission.

(D) If, as the result of any review, the MassHealth agency determines that any hospital inpatient admission, stay, or service provided to a member was not covered under the member's coverage type (see 130 CMR 450.105: Coverage Types) or was delivered without obtaining a required authorization including, where applicable, authorization from the member's primary-care provider, the MassHealth agency will not pay for that inpatient admission, stay, or service.

Notes

130 CMR 415.414

Amended by Mass Register Issue S1277, eff. 1/2/2015.