(a) HHSC uses recognized evidence-based guidelines
for inpatient hospital screening criteria. Non-physician reviewers
use the guidelines as criteria for the initial approval or for the
referral of inpatient reviews for medical necessity decisions. If
the criteria are not met or if the non-physician reviewer has any
questions concerning the appropriateness of coding or quality of care,
the non-physician reviewer refers the medical record to a physician
consultant under contract with HHSC for a decision. Even if the criteria
are met, the physician consultant may determine that an inpatient
admission was not medically necessary, and HHSC issues an admission
denial. 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. A physician consultant may determine that an inpatient
admission was not medically necessary if a physician admitted a patient
in observation status and the patient was discharged from the outpatient
status within the Texas Medicaid Provider Procedures Manual, or any
subsequent provider manuals, defined observation period.
(b) For the purposes of the TMRP, TEFRA, and facility-specific
per diem methodology reviews, medical necessity means that the patient
has a condition requiring treatment that can be safely provided only
in the inpatient setting.
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Source Note: The provisions of this §371.204 adopted to be effective June 14, 1989, 14 TexReg 2624; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308; amended to be effective March 30, 2003, 28 TexReg 2481; amended to be effective January 11, 2004, 29 TexReg 357; amended to be effective August 1,2006, 31TexReg 5603; amended to be effective January 1, 2014, 38 TexReg9479; amended to be effective May 1, 2016, 41 TexReg 2941 |