SECTION 371.210. Inpatient Utilization Review for Hospitals Reimbursed Under TMRP and TEFRA Principles of Reimbursement and Facility-Specific Per Diem Methodology Reviews

(a) The TEFRA and facility-specific per diem methodology reviews process includes the following:

(1) Admission review to evaluate the medical necessity of the admission. For purposes of the TMRP, TEFRA, and facility-specific reviews, medical necessity means the patient has a condition requiring treatment that can be safely provided only in the inpatient setting.

(2) Continued stay review to verify the medical necessity of each day of stay.

(3) Quality of care review to assess whether the quality of care provided meets generally accepted standards of medical and hospital care practices or puts the patient at risk of unnecessary injury or death. Quality of care review includes the use of discharge screens and generic quality screens. If quality of care issues are identified, physician consultants under contract with HHSC and of the specialty related to the care provided determine possible clinical recommendations or corrective actions.

(b) HHSC reviews the complete medical record for the requested admission(s) to make decisions on all aspects of this review process. The complete medical record may include: emergency room records, medical/surgical history and physical examination, discharge summary, physicians' progress notes, physicians' orders, lab reports, diagnostic and imaging reports, operative reports, pathology reports, nurses' notes, medication sheets, vital signs sheets, therapy notes, specialty consultation reports, and special diagnostic and treatment records. If the complete medical record is not available during the review, HHSC issues a preliminary technical denial and notifies the facility.

(c) A physician consultant under contract with HHSC makes all decisions concerning medical necessity, cause of readmission, and appropriateness of setting for the service provided. In the event the physician consultant determines the services were not medically necessary, should have been provided in a previous admission, or were not provided in the appropriate setting, the claim is denied, and HHSC notifies the hospital in writing. 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. Physicians and/or non-physician providers are notified in writing if the claim for professional services is denied. The written notification explains the process for appealing the denial.

Source Note: The provisions of this §371.210 adopted to be effective June 14, 1989, 14 TexReg 2624; amended to be effective February 1, 1991, 16 TexReg 232; amended to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective November 22, 1995, 20 TexReg 9274; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25TexReg 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 January 1, 2014, 38 TexReg 9479; amended to be effective May 1, 2016, 41 TexReg 2941