26 Tex. Admin. Code § 270.16 - Medical Necessity Assessments
(a) The provider
agency must complete a medical necessity and level of care assessment based on
the client's total needs.
(b) The
provider agency must electronically transmit the medical necessity and level of
care assessment to the agency with which the Texas Health and Human Services
Commission (HHSC) contracts for medical necessity determinations.
(c) The provider agency must enroll any
eligible applicant within 60 calendar days after the date of the medical
necessity and level of care assessment.
(d) The provider agency must complete another
medical necessity and level of care assessment and submit it to the agency with
which HHSC contracts for medical necessity determinations 12 months after the
initial assessment.
(1) If the client meets
the state's medical necessity criteria and the client has an irreversible or
progressive diagnosis, or a terminal illness that could reasonably be expected
to result in death in the next six months, and the Department of Aging and
Disability Services (DADS) determines that there is no reasonable expectation
of improvement or significant change in the client's condition because of
severity of a chronic condition or the degree of impairment of functional
capacity, DADS will permanently waive the annual recertification requirement
and the client may be deemed to be continually eligible for PACE. The medical
necessity and level of care assessment must have sufficient documentation to
substantiate the client's prognosis and the client's functional
capacity.
(2) In addition, if DADS
determines that a PACE client no longer meets the medical necessity criteria
for nursing facility care, the client may be deemed to continue to be eligible
for PACE until the next annual reassessment, if, in the absence of PACE
services, it is reasonable to expect that the client would meet the nursing
facility medical necessity criteria within the next six months.
(e) The provider agency's licensed
nurse must complete the medical necessity and level of care assessment for the
provider agency. The licensed nurse must be registered with the agency with
which HHSC contracts for medical necessity determinations as having, within the
last two years, received and passed a state-approved training on the medical
necessity and level of care assessment.
Notes
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