4109

4109.1 In accordance with 42 C.F.R. § 456.401, each ICF/IID shall develop, implement, and maintain a written Utilization Review Plan (URP) for each Medicaid beneficiary receiving services furnished by the ICF/IID. The URP shall provide for a review of each beneficiary's need for the services that the ICF furnished him or her.

4109.2 Utilization review for ICFs/IID enrolled in D.C. Medicaid may be conducted by any of the following:

1. (a) The ICF/IID;
2. (b) DHCF or its designee; or
3. (c) Any other approved method.

4109.3 The URP shall, at minimum, include the following:

1. (a) A description of how utilization review shall be performed;
2. (b) The frequency of utilization review;
3. (c) Assurances and documentation establishing that the personnel who shall perform utilization review meet the requirements of 42 C.F.R. § 456.406;
4. (d) Administrative staff responsibilities related to utilization review;
5. (e) The types of records maintained by the utilization review team;
6. (f) The types and frequency of any reports developed by the utilization review team, and related plan for dissemination; and
7. (g) The procedures that shall be used when corrective action is necessary.

4109.4 In accordance with 42 C.F.R. §§ 456.431 - 456.438, each URP shall establish a process whereby each individual residing in the ICF/IID receives continued stay reviews, at minimum, every six (6) months.

4109.5 The URP shall establish written methods and criteria used to conduct continued stay reviews. The URP shall also set forth enhanced criteria used to assess a case if the individual's circumstances reflect any of the following associations:

(a) High costs;

(b) Frequent and excessive services; or

(c) Attended by a physician or other practitioner whose practices reflect questionable billing patterns or misrepresentation of facts needed in order to secure claims reimbursement, including but not limited to ordering and/or providing services that are not medically necessary or that fail to meet professionally recognized standards of care.

SOURCE: Final Rulemaking published at 60 DCR 11590 (August 9, 2013); as amended by Final Rulemaking published at 61 DCR 12231 (November 28, 2014); as amended by Final Rulemaking published at 63 DCR 297 (January 8, 2016).