1 Tex. Admin. Code § 371.210 - Inpatient Utilization Review for Hospitals Reimbursed Under TMRP and TEFRA Principles of Reimbursement and Facility-Specific Per Diem Methodology Reviews
(a) The TEFRA and
facility-specific per diem methodology reviews process includes the following:
(1) Admission review to evaluate the medical
necessity of the admission. For purposes of the TMRP, TEFRA, and
facility-specific reviews, medical necessity means the patient has a condition
requiring treatment that can be safely provided only in the inpatient
setting.
(2) Continued stay review
to verify the medical necessity of each day of stay.
(3) Quality of care review to assess whether
the quality of care provided meets generally accepted standards of medical and
hospital care practices or puts the patient at risk of unnecessary injury or
death. Quality of care review includes the use of discharge screens and generic
quality screens. If quality of care issues are identified, physician
consultants under contract with HHSC and of the specialty related to the care
provided determine possible clinical recommendations or corrective
actions.
(b) HHSC
reviews the complete medical record for the requested admission(s) to make
decisions on all aspects of this review process. The complete medical record
may include: emergency room records, medical/surgical history and physical
examination, discharge summary, physicians' progress notes, physicians' orders,
lab reports, diagnostic and imaging reports, operative reports, pathology
reports, nurses' notes, medication sheets, vital signs sheets, therapy notes,
specialty consultation reports, and special diagnostic and treatment records.
If the complete medical record is not available during the review, HHSC issues
a preliminary technical denial and notifies the facility.
(c) A physician consultant under contract
with HHSC makes all decisions concerning medical necessity, cause of
readmission, and appropriateness of setting for the service provided. In the
event the physician consultant determines the services were not medically
necessary, should have been provided in a previous admission, or were not
provided in the appropriate setting, the claim is denied, and HHSC notifies the
hospital in writing. If a hospital claim is denied for lack of medical
necessity or for being provided in an inappropriate setting, HHSC considers for
denial physician and/or non-physician Medicaid provider claims associated with
the hospital admission or service when such claims can be identified and are
deemed to be the result of inappropriate admission orders. Physicians and/or
non-physician providers are notified in writing if the claim for professional
services is denied. The written notification explains the process for appealing
the denial.
Notes
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