New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 1 - GENERAL PROVISIONS › Section 10:52-1.15 - Utilization control (inpatient services)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section provides information on the requirements for utilization control for inpatient services for approved acute general hospitals, special hospitals, and private psychiatric hospitals, with the exception of inpatient psychiatric hospital services for individuals under the age of 21. See 10:52-1.16.
(b) For purposes of this rule, the following words and terms shall have the following meanings:
"Utilization control" means an approved program instituted, implemented and operated by or under the authorization of a utilization review organization (URO) which effectively safeguards against unnecessary or inappropriate Medicaid/NJ FamilyCare services and assesses the quality of those services to Medicaid/NJ FamilyCare fee-for-service beneficiaries.
(c) Under the Social Security Act, Section 1903(g) and (h), the Division is responsible for an effective program to control the utilization of services in hospitals. (See 42 CFR Part 456, Utilization Control, Subchapter B, C, and D). The required reviews of inpatient hospital services shall be conducted by Quality Improvement Organizations (QIOs), which shall be reimbursed by the State once a contract has been secured to provide these services in accordance with N.J.A.C. 10:52-14.6(a)2i. Included under utilization control are: Certification and recertification of the need for inpatient care; medical, psychiatric and social evaluations; a plan of care established and periodically reviewed and evaluated by a physician; and a continuous program of utilization review under which the admission of each beneficiary is reviewed or screened. Hospital entitlement to Medicaid/NJ FamilyCare reimbursement for services rendered to a Medicaid/NJ FamilyCare fee-for-service beneficiary for each period of hospitalization shall be subject to the following requirements:
1. A physician shall certify, for each beneficiary or applicant, that inpatient services in the acute care or in the private psychiatric hospital are or were needed.
i. The certification shall be made at the time of admission or, if an individual applies for assistance while in a hospital, before the Medicaid/NJ FamilyCare program authorizes payment.
ii. The certification shall be in writing and signed, or initialed, by a physician. The signature or initials are not acceptable if they are rubber stamped unless the physician has initialed the stamped signature. The physician shall date the certification on the date he or she signs it.
iii. The certification for any Medicaid/NJ FamilyCare fee-for-service patient shall be maintained in the beneficiary's medical record.
iv. Acceptable documentation for certification or recertification may be any of the following:
(1) A statement signed and dated, by the attending physician, staff physician, and/or consultant physician who has knowledge of the case, attesting that the beneficiary is in need of hospital care.
(2) Physician's orders which are signed and dated on admission and clearly attest to the need for hospital care.
(3) A medical evaluation which designates the services and which is signed and dated by a physician who has knowledge of the case.
(4) An admission review form signed and dated by an attending or staff physician who has knowledge of the case.