R414. Health and Human Services, Health Care Financing, Coverage and Reimbursement Policy.R414-515. Long-Term Acute Care.
R414-515-1. Purpose and Authority.
(1) This rule defines the scope of inpatient long-term acute care (LTAC) hospital services available to Medicaid members to treat disorders other than mental disease.
(2) This rule is authorized by Subsection 1886(d)(1)(B) of the Social Security Act and Sections 26B-1-213, 26B-3-102, 26B-3-104, and 26B-3-108.
R414-515-2. Definitions.
(1) "Admission" means the acceptance of a Medicaid member for LTAC and treatment when the member meets established evidence-based criteria for severity of illness and intensity of service and the required service cannot be provided in a lesser level-of-care setting.
(2) "Comprehensive documentation" means applicable, relevant information including a history and physical, operative reports, daily physician progress notes, vital signs, laboratory test results, medications administration records, respiratory therapy notes, wound care notes, nutrition notes, physical therapy notes, occupational therapy notes, speech therapy notes, and other pertinent information the Division of Integrated Healthcare needs to decide on an LTAC request.
(3) "Continued stay review" means a periodic, supplemental, or interim review of clinical information for an LTAC member.
(4) "Inpatient" means an individual whose severity of illness and intensity of service meet the evidence-based criteria for an LTAC hospital stay.
(5) "Intensity of service" means the measure of the number, technical complexity, or attendant risk of services provided.
(6) "LTAC" hospital means an inpatient transitional care hospital designed to treat members with multiple, serious medical conditions requiring intense, acute care as determined by a physician.
(7) "Retroactive review" means a review of clinical information for a patient who had previously been admitted to an LTAC hospital, but never received prior authorization for the initial or continued stay due to retroactive eligibility approval.
(8) "Severity of illness" means the extent of a member's organ system derangement or physiologic decompensation.
R414-515-3. Client Eligibility Requirements.
LTAC hospital services are available to categorically and medically needy individuals.
R414-515-4. Program Access Requirements.
(1)(a) A member must meet the severity of illness and intensity of service for LTAC hospital level-of-care as determined through an evidence-based criteria review process.
(b) The Department shall deny an LTAC request for reimbursement if the member does not meet the evidence-based criteria.
(2) The Department may forward LTAC preadmissions, continued stays, and retroactive stays that do not meet the evidence-based criteria for secondary medical review if:
(a) the LTAC provider requests the secondary medical review; or
(b) review of documentation shows that LTAC is the most appropriate level-of-care for the member.
R414-515-5. Service Coverage.
(1) A member must receive prior authorization for preadmission, continued stay, and retroactive reviews.
(2) An LTAC provider must submit to the Department a request for coverage that includes current and comprehensive documentation, or the Department will return the request as incomplete.
(3) The Department shall consider LTAC coverage upon the date it receives the request with current, comprehensive documentation.
(4) The Department shall review the documentation to determine preadmission, continued stay, or retroactive stay within three business days of the request.
(5) An LTAC provider may not transfer prior authorization to another LTAC provider.
(6) If a member transfers from an LTAC hospital to an acute care hospital for any reason, and is away from the LTAC hospital for more than 24 hours, the LTAC provider shall submit a new preadmission review before transferring the member back to the LTAC hospital.
(7) The Department authorizes each approved prior authorization for up to 28 days.
R414-515-6. Preadmission Review.
An LTAC provider shall submit prior authorization requests to the Department at least 24 hours before admission. If a member does not admit within 48 hours of approval, the LTAC provider must submit a new prior authorization.
R414-515-7. Continued Stay Review.
