Connecticut Administrative Code › Title 17 - Public Assistance and Welfare Services › 134d - Medical Assistance › Title XIX Rates for Community Health Centers › Section 17-134d-80 - Title XIX utilization review requirements for medicaid services in general hospitals

Current through July 10, 2024
(a)
Definitions
For purposes of this regulation, the following definitions
				  apply:
(1) Acute Care means the
				medical care needed for an illness, episode, or injury which requires short
				term, intense care and hospitalization for a short period of time.
(2) Admission means the formal acceptance by
				a hospita1 of a patient who is to receive health care services while lodged in
				an area of the hospital reserved for continuous nursing services.
(3) Adverse Determination means the initial
				negative decision by a reviewing body regarding the medical necessity, quality,
				or appropriateness of health care services provided or proposed to be provided
				to a patient.
(4) Appropriateness
				of Setting Review means the review of services provided or proposed to be
				provided to determine if the services could have been delivered safely,
				effectively and more economically in another setting.
(5) Criteria means the pre-determined
				measurement variables on which judgment or comparison of necessity,
				appropriateness or quality of health services may be made.
(6) Department means the State of Connecticut
				Department of Income Maintenance or its agent.
(7) Department's Manual means the
				Department's Connecticut Medical Assistance Provider Manual, which contains the
				Medical Services Policy, as amended from time to time.
(8) Diagnosis
(A) Admitting Diagnosis means the patient's
				condition which necessitated or prompted the admission to the hospital, and
				coded according to International Classification of Diseases, 9th Revision,
				Clinical Modification, and as amended from time to time.
(B) Principal Diagnosis means the condition
				established after study to be chiefly responsible for occasioning the admission
				of the patient to the hospital for care and coded using International
				Classification of Diseases, 9th Revision, Clinical Modification, and as amended
				from time to time.
(9)
				Emergency means a medical condition (including labor and delivery) manifesting
				itself by acute symptoms of sufficient severity (including severe pain) such
				that the absence of immediate medical attention could reasonably be expected to
				result in placing the patient's health in serious jeopardy, serious impairment
				to bodily functions, or serious dysfunction of any bodily organ or
				part.
(10) Evaluation means an
				assessment or examination in which actions and their results are measured
				against predetermined criteria in order to verify medical necessity,
				appropriateness, and quality.
(11)
				Free Standing Clinic means a facility providing medical or medically related
				clinic outpatient services or clinic off-site services by or under the
				direction of a physician or dentist and the facility is not part of, or related
				to, a hospital. Such facilities provide mental health, rehabilitation, dental
				and medical services and are subject to Sections 171 through 171.4 of the
				Department's Manual, as may be amended from time to time.
(12) General Hospital for purposes of this
				regulation means a short-term hospital having facilities, medical staff and all
				necessary personnel to provide diagnosis, care and treatment of a wide range of
				acute conditions, including injuries, and shall include a children's general
				hospital which means a short-term hospital having facilities, medical staff and
				all necessary personnel to provide diagnosis, care and treatment of a wide
				range of acute conditions among children, including injuries. It shall also
				include a border hospital as defined in Section 150.1 of the Department's
				Manual, as may be amended from time to time.
(13) Inpatient means a recipient who has been
				admitted to a general hospital for the purpose of receiving medically
				necessary, appropriate, and quality medical, dental or other health related
				services and is present at midnight for the census count.
(14) Medical Appropriateness means medical
				care that is provided in a timely manner and meets professionally recognized
				standards of acceptable medical care and is delivered in the appropriate
				medical setting.
(15) Medical
				Necessity means medical care provided to:
(A)
				Correct or diminish the adverse effects of a medical condition;
(B) Assist an individual in attaining or
				maintaining an optimal level of well being;
(C) Diagnose a condition; or
(D) Prevent a medical condition from
				occurring.
(16) Override
				Option means a decision, used in utilization review, when "overriding"
				circumstances of clinical significance justify changing the conclusion of the
				objective criteria.
(17) Patient
				means an individual who receives a health care service from a provider and is
				also a Medicaid recipient.
(18)
				Preadmission Review means a review prior to or in the case of an emergency
				admission, immediately thereafter, a patient's admission to a hospital to
				determine the medical necessity, appropriateness, and quality of the health
				care services proposed to be delivered, or in the case of an emergency,
				delivered in the hospital.
(19)
				Principal Procedure means the procedure most closely related to the principal
				diagnosis, that is performed for definitive treatment rather than one performed
				for diagnostic or exploratory purposes and/or was necessary to care for a
				complication, and coded according to International Classification of Diseases,
				9th Revision, Clinical Modification, and as amended from time to
				time.
(20) Prior Authorization
				means approval for a service from the Department or the Department's agent
				before the provider actually provides the service. In order to receive
				reimbursement from the Department a provider must comply with all prior
				authorization requirements. The Department in its sole discretion determines
				what information is necessary in order to approve a prior authorization
				request.
In the case of an emergency admission to a general hospital,
				  prior authorization means approval obtained within two business days of
				  admission.
(21) Quality of
				Care means the evaluation of medical care to determine if it meets the
				professionally recognized standard(s) of acceptable medical care for the
				condition and the patient under treatment.
(22) Recipient means an individual who has
				been determined eligible for Medicaid.
(23) Reliability means a measure of the
				consistency of a method in producing results. A reliable test gives the same
				results when applied more than once under the same conditions.
(24) Retrospective Review means the review
				conducted after services are provided to a patient, to determine the medical
				necessity, appropriateness, and quality of the services provided.
(25) Utilization Review means the evaluation
				of the necessity, appropriateness, and quality of the use of medical services,
				procedures and facilities. Utilization review evaluates the medical necessity,
				and medical appropriateness of admissions, the services performed or to be
				performed, the length of stay and the discharge practices. It is conducted on a
				prospective and/or retrospective basis.
(26) Validity means a measure of the extent
				to which an observed situation reflects the true situation or an indication of
				medical quality measures what it purports to measure.