| (ii) Should a medical condition develop or be discovered that necessitates a change in the original admitting diagnosis to a more severe diagnosis, which would require additional hospital services above and beyond the non-emergency inpatient services authorized through the initial hardship exemption procedure, any additional inpatient services rendered will not be covered unless the hospital receives an authorization for subsequent inpatient services to be rendered. (I) Should an emergency medical condition develop or be discovered, the procedures for a non-contracted hospital providing emergency inpatient services as explained at subparagraph (A) of this paragraph must be adhered too. (II) Any emergency case in a non-contracted hospital with a normal DRG Length-of-Stay of 72 hours or less; or any normal DRG Length-of-Stay over 72 hours that is stabilized and discharged home within 72 hours from the initial admission will be granted an automatic exception. (III) Should a medical condition develop or be discovered that necessitates a transfer of the patient to a contracted hospital, the non-contracted hospital will be reimbursed, utilizing the current transfer methodology. (iii) As in current policy, each case will continue to be subject to all relevant utilization review criteria. (j) Reimbursement for inpatient mental health facilities. Inpatient mental health facilities in MSAs where the LoneSTAR Select Contracting Program II awards amended provider agreements will have their inpatient psychiatric services reimbursed as follows. (1) Inpatient mental health facilities awarded selective provider agreements will be reimbursed for all covered emergency services according to the proposed rates they submit with their proposals or according to the final negotiated rates that all parties agree will serve as the reimbursement mechanism for all covered emergency services rendered by the health care provider. (2) Inpatient mental health facilities not awarded selective provider agreements will be reimbursed for covered emergency inpatient services as currently stated in the State Plan until the patient is stabilized. After a patient is stabilized in a non-contracted health care provider, inpatient services are no longer covered unless the non-contracted health care provider receives an exception for some additional days of stay. (3) As in current policy, each case will continue to be subject to all relevant utilization review criteria. |
| Source Note: The provisions of this §355.8321 adopted to be effective July 27, 1994, 19 TexReg 5485; amended to be effective February 14, 1995, 20 TexReg 564; amended to be effective November 22, 1995, 20 TexReg 9274; duplicated effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660 |
