130 CMR 450.209 - Utilization Management: Prepayment Review for Acute Inpatient Hospitals
(A)
Introduction.
(1) The MassHealth agency conducts prepayment
reviews to evaluate acute inpatient hospital admissions for
(a) medical necessity including, but not
limited to, the appropriateness of the inpatient admission and any
services;
(b) the stability of the
member at the time of discharge;
(c) the quality of care provided;
and
(d) compliance with the
MassHealth agency's billing procedures and requirements.
(2) The MassHealth agency will identify each
admission to be reviewed by mailing to the acute inpatient hospital a request
for selected medical records.
(B)
Submission Requirements and
Time Frames.
(1) The acute
inpatient hospital must submit the requested medical records to the MassHealth
agency. Such medical records must be received by the MassHealth agency within
17 calendar days of the date appearing on the request. If the hospital fails to
timely submit the records, the MassHealth agency will deny payment for the
admission.
(2) If the MassHealth
agency concludes that the records submitted are incomplete, it will inform the
acute inpatient hospital in writing. The hospital must submit the documents
that were missing from the medical record or records to the MassHealth agency.
Such documents must be received by the MassHealth agency within 17 calendar
days of the date appearing on the MassHealth agency's notice requesting such
information. If the hospital fails to timely submit the documents to complete
the medical record, the MassHealth agency will deny payment for the
admission.
(3) The acute inpatient
hospital may request reconsideration of any denials issued in accordance with
130 CMR 450.209(B)(1) or (2). Such a request must be made in writing and
received by the MassHealth agency within 33 calendar days of the date appearing
on the denial notice, and must include the complete medical record or records.
If the hospital requests reconsideration pursuant to 130 CMR 450.209(B)(3), the
MassHealth agency will review the medical record or records and notify the
hospital of the determination. If the hospital does not timely request
reconsideration, the denial issued pursuant to 130 CMR 450.209(B)(1) or (2)
constitutes the MassHealth agency's final action, and the hospital will have no
right to an adjudicatory hearing pursuant to 130 CMR 450.209(C)(3), because of
its failure to exhaust its administrative remedies.
(C)
Determination of
Noncompliance.
(1)
MassHealth Agency's Determination. If, based on its
review of the information submitted in accordance with 130 CMR 450.209(B), the
MassHealth agency determines that an acute hospital inpatient admission was not
medically necessary, the MassHealth agency will deny payment for the admission.
The hospital may rebill for medically necessary services as an outpatient claim
pursuant to
130 CMR
415.414: Utilization Review.
If, based on its review, the MassHealth agency determines that the admission
was medically necessary but the hospital has failed to comply with the
MassHealth agency's billing procedures and requirements, the MassHealth agency
will deny the claim. In such a case, the hospital may rebill the claim pursuant
to the proper billing requirements.
(2)
Requesting
Reconsideration.
(a) The acute
inpatient hospital must request reconsideration of any denial issued in
accordance with 130 CMR 450.209(C)(1) in order to be entitled to file a claim
for an adjudicatory hearing pursuant to
130 CMR
450.241. Such reconsideration request must be
made in writing and received by the MassHealth agency within 33 calendar days
of the date appearing on the denial notice, and must include the following:
1. a written statement from a physician
explaining why the MassHealth agency's denial was in error. Such explanation
must specifically address all clinical issues cited in the MassHealth agency's
denial and must not consist solely of the resubmission of previously submitted
documents;
2. a certification from
the acute inpatient hospital's Utilization Review Department (URD) that it has
reviewed the medical record or records and believes that both the treatment
delivered and the inpatient admission were in compliance with all MassHealth
agency regulations about the medical or administrative necessity of the
admission, treatment, and continued stay of that patient; and
3. if the MassHealth agency's denial
indicates that any service should have been delivered as an outpatient service,
the physician statement and URD certification must explain why this would have
been contrary to accepted standards of medical practice.
(b) If the hospital does not submit a request
for reconsideration, the denial issued pursuant to 130 CMR 450.209(C)(1)
constitutes the MassHealth agency's final action. If the hospital requests
reconsideration but fails to timely comply with the requirements of 130 CMR
450.209(C)(2)(a), the reconsideration request will be summarily denied. In
either case, the MassHealth agency's denial constitutes the MassHealth agency's
final action, and the hospital has no right to an adjudicatory hearing pursuant
to 130 CMR 450.209(C)(3) or judicial review because of its failure to exhaust
its administrative remedies.
(3)
MassHealth Agency's Final
Determination. The MassHealth agency will review a request for
reconsideration and accompanying material submitted in compliance with the
requirements of 130 CMR 450.209(C)(2) and will issue a final determination
based on such review. The determination will be in writing, state the reasons
for the determination, and inform the acute inpatient hospital of its right to
file a claim for an adjudicatory hearing in accordance with
130 CMR
450.241. The claim will be decided by the
Office of Medicaid's Board of Hearings in accordance with
130 CMR
450.241 through
450.248.
(D)
Resubmission of
Claim after Denial or Pending Review. If the acute inpatient
hospital resubmits an inpatient claim for payment that, pursuant to 130 CMR
450.209, has either been denied or is pending review, and if that resubmitted
claim is paid by the MassHealth agency, the MassHealth agency will void the
payment of the claim when it becomes aware of the resubmission. The hospital
may file a claim for an adjudicatory hearing pursuant to
130 CMR
450.241 and
450.243
through
450.248
to contest the voiding of the payment.
Notes
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