Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.020 - Procedures for Admission Certification, Continued Stay Review, and Validation Review of Hospital Admissions

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment adds the definition of
				  "written request" which allows the ability to email or fax the record request
				  letters to providers.
(1) The
				following definitions will be used in administering this rule:
(A) Admission. Admission means the act of
				registration and entry into a general medical and surgical, psychiatric, or
				rehabilitation hospital on the order of a qualified medical practitioner or
				medical professional having privileges of admission for the purpose of
				providing inpatient hospital services under the supervision of a physician
				member of the hospital's medical staff;
(B) Admission certification. Admission
				certification means the determination by the medical review agent, as
				transmitted to the hospital/physician and the fiscal agent, that the admission
				of a participant for inpatient hospital services is approved as medically
				necessary, reasonable, and appropriate as to placement at an acute level of
				care;
(C) Admitting diagnosis.
				Admitting diagnosis means the physician's tentative or provisional diagnosis of
				the participant's condition as a basis for examination and treatment when the
				admission certification is requested;
(D) Admitting medical professional. Admitting
				medical professional means a physician or other person authorized by state
				licensure law to order hospital services and who has admission privileges to
				order the participant's inpatient admission to the hospital;
(E) Certification number. Certification
				number means the number issued by the medical review agent that establishes
				that, based upon information furnished by the provider, a participant's
				admission for inpatient hospital services is approved as medically necessary;
(F) Department. Department means
				the Missouri Department of Social Services;
(G) Emergency admission. Emergency admission
				means an admission in which the medical condition manifests itself by acute
				symptoms of sufficient severity (including severe pain) that absence of
				immediate medical attention could reasonably be expected to result in placing
				the patient's health in serious jeopardy, serious impairment to bodily function
				or serious dysfunction of any bodily organ or part;
(H) Fee for service. Fee for service refers
				to participants and/or services not included in the MO HealthNet Managed Care
				program or other prepaid health plans;
(I) Inpatient hospital service. Inpatient
				hospital service means a service provided by or under the supervision of a
				medical professional after a participant's admission to a hospital and
				furnished in the hospital for the care and treatment of the
				participant;
(J) Managed Care.
				Managed Care is a program under which some MO HealthNet participants are
				enrolled with a health plan who contracts with the department to provide a
				package of MO HealthNet benefits for a monthly fee per enrollee;
(K) Medical record. Medical record means all
				or any portion of the medical record as requested by the medical review agent;
(L) Medical review agent. Medical
				review agent means the state's representative who is authorized to make
				decisions about admission certifications and validation reviews;
(M) Medically necessary. Medically necessary
				means an inpatient hospital service that is consistent with the participant's
				diagnosis or condition and is in accordance with the criteria as specified by
				the department;
(N) Nurse
				reviewer. Nurse reviewer means a person who is employed by or under contract
				with the medical review agent and who is licensed to practice professional
				nursing in Missouri;
(O) Pertinent
				information. Pertinent information means any information that the physician,
				hospital, or participant feels may justify or qualify the hospitalization;
(P) Physician reviewer. Physician
				reviewer means a physician who is a peer of the admitting/ attending physician
				or who specializes in the type of care under review. Exceptions will be made
				only if the efficiency or effectiveness of the review would be compromised, but
				in every situation the review will be performed by a physician;
(Q) Readmission. Readmission means an
				admission that occurs within fifteen (15) days of a discharge of the same
				participant from the same or a different hospital. The fifteen- (15-) day
				period does not include the day of discharge or the day of readmission;
(R) Participant. Participant means
				a person who has applied and been determined eligible for MO HealthNet
				benefits;
(S) Reconsideration.
				Reconsideration means a review of a denial or withdrawal of admission
				certification;
(T) Required
				information. Required information means the information to be provided by the
				medical professional or hospital to obtain a preadmission or post-admission
				certification, which includes participant, medical professional, and hospital
				identifying information, admission date, admission diagnosis, procedures,
				surgery date, indications for inpatient setting, and plan of care;
(U) Transfer. Transfer means the movement of
				a participant after admission from one (1) hospital directly to another or
				within the same facility;
(V)
				Urgent admission. Urgent admission means a case which requires prompt admission
				to the hospital to prevent deterioration of a medical condition from an urgent
				to an emergency situation;
(W)
				Utilization review assistant. Utilization review assistant means a person who
				is employed by or is under contract with the medical review agent who is the
				preliminary reviewer to assess the need for nurse review when the Milliman Care
				Guidelines is not immediately met;
(X) Validation review. Validation review
				means a review conducted after admission certification has been approved. The
				review is focused on validating the admitting information and confirming the
				determination of medical necessity of the admission; and
(Y) Written Request. A notice to the address
				of the provider as listed in the MO HealthNet Division's system, in writing,
				transmitted via the U.S. mail or other private or common carrier, facsimile,
				e-mail, or any other method/mode of transmittal that is deemed by MO HealthNet
				to be an efficient, cost-effective, verifiable, and a reliable method or mode
				of communication with the provider, applying provider, or provider's
				representative.