1. (a) A team specified in 42 C.F.R. § 441.154 must certify that:

   1. (1) Ambulatory care resources available in the community do not meet the treatment needs of the resident;
   2. (2) Proper treatment of the recipients’ psychiatric condition requires services on an inpatient basis under the direction of a physician;
   3. (3) The services can reasonably be expected to improve the resident’s condition or prevent further regression so that the services will no longer be needed; and
   4. (4) All other certification of need requirements in 42 C.F.R. §§ 441.150 – 441.156.

2. (b) Residents with Medicaid managed care organization payors.

   1. (1)

      1. (A) If a resident receives notice of an adverse benefit determination and timely requests an appeal and continuation of benefits in accordance with 42 C.F.R. § 438.420, a PRTF will remain in compliance with certification of need requirements as identified under 42 C.F.R. pt. 441 while the appeal or state fair hearing is pending.
      2. (B) The benefits must be continued if all of the following occur:

3. (i) The resident or their guardian files the request for an appeal timely in accordance with 42 C.F.R. § 438.402(c)(1)(ii) and (c)(2)(ii);

   1. (ii) The appeal involves the termination, suspension, or reduction of previously authorized services;

      1. (iii) The services were ordered by an authorized provider;

         1. (iv) The period covered by the original authorization has not expired; and
         2. (v) The resident or their guardian timely files for continuation of benefits.

   2. (2) Continued or reinstated benefits must be continued until one (1) of the following occurs:

      1. (A) The resident withdraws the appeal or request for state fair hearing;
      2. (B) The resident fails to request a state fair hearing and continuation of benefits within ten (10) days of the notice of adverse resolution of an appeal;
      3. (C) A state hearing officer issues a hearing decision adverse to the enrollee.
   3. (3) All other continuation of benefits requirements in 42 C.F.R. § 438.420.

Codification Notes: "PRTF" means a psychiatric residential treatment facility.