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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 3LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
SUBCHAPTER HHSTANDARDS FOR REASONABLE COST CONTROL AND UTILIZATION REVIEW FOR CHEMICAL DEPENDENCY TREATMENT CENTERS
RULE §3.8012Continued Stay Criteria for Inpatient Rehabilitation/Treatment (Hospital or 24-hour Residential) Services

(a) Eligibility for continued stay in an inpatient rehabilitation/treatment (hospital or 24-hour residential) program shall be based on the patient's meeting at least one of the conditions in paragraph (1) or (2) of this subsection.

  (1) Chemical dependency rehabilitation/treatment complication. The patient must meet the conditions in subparagraph (A) or (B) of this paragraph.

    (A) Patient recognizes or identifies with the severity of the alcohol and/or drug problem, but demonstrates minimal insight into the patient's defeating use of alcohol/drugs, but documentation in the record indicates that the patient is progressing in treatment.

    (B) Patient:

      (i) identifies with the severity of the patient's alcohol and/or drug problem and manifests insight into the patient's personal relationship with mood-altering chemicals, yet does not demonstrate behaviors indicating that the patient is developing problem solving skills necessary to cope with the problem; and

      (ii) would predictably relapse if moved to a lesser level of care.

  (2) Psychiatric or medical complications. The patient must meet the conditions in subparagraph (A) or (B) of this paragraph.

    (A) Documentation in the record indicates an intervening medical or psychiatric event which was serious enough to interrupt rehabilitation/treatment, but the patient is again progressing in treatment.

    (B) Documentation in the record indicates that the patient is being held pending an immediate transfer to a psychiatric, acute medical service, or inpatient detoxification alcohol/drug service.

(b) In determining the utilization review points discussed in §3.8014 of this title (relating to Recommended Length of Stay for Inpatient Rehabilitation/Treatment (Hospital or 24-hour Residential) Services), the criteria in subsection (a)(1) and (2) of this section shall be considered.


Source Note: The provisions of this §3.8012 adopted to be effective August 28, 1991, 16 TexReg 4403.

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