PURPOSE: The Division of Medical Services establishes admission certification and validation procedures on which hospitals furnishing inpatient care to Medicaid recipients will be reviewed to determine that admissions are medically necessary and appropriate for inpatient care.

Editor’s Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office of the Secretary of State or at the headquarters of the agency and is available to any interested person at a cost established by state law.

1. (1) The following definitions will be used in administering this rule:

   1. (A) Admission. Admission means the act of registration and entry into a general medical and surgical, psychiatric or rehabilitation hospital on the order of a qualified medical practitioner having privileges of admission for the purpose of providing inpatient hospital services under the supervision of a physician member of the hospital’s medical staff;
   2. (B) Admission certification. Admission certification means the determination by the medical review agent, as transmitted to the hospital/physician and the fiscal agent, that the admission of a recipient for inpatient hospital services is approved as medically necessary, reasonable and appropriate as to placement at an acute level of care;
   3. (C) Admitting diagnosis. Admitting diagnosis means the physician’s tentative or provisional diagnosis of the recipient’s condition as a basis for examination and treatment when the physician requests admission certification;
   4. (D) Admitting physician. Admitting physician means the physician who orders the recipient’s admission to the hospital;
   5. (E) Certification number. Certification number means the number issued by the medical review agent that establishes that, based upon information furnished by the provider, a recipient’s admission for inpatient hospital services is approved as medically necessary;
   6. (F) Department. Department means the Missouri Department of Social Services;
   7. (G) Emergency admission. Emergency admission means an admission in which the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) that absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily function or serious dysfunction of any bodily organ or part;
   8. (H) Fee for service. Fee for service refers to recipients and/or services not included in the MC+ Missouri Managed Care program or other prepaid health plans;
   9. (I) Inpatient hospital service. Inpatient hospital service means a service provided by or under the supervision of a physician after a recipient’s admission to a hospital and furnished in the hospital for the care and treatment of the recipient;
   10. (J) MC+. MC+ is the Missouri Medicaid “Managed Care Plus” program under which some Medicaid recipients are enrolled with a health plan who contract with the department to provide a package of Medicaid benefits for a monthly fee per enrollee:
   11. (K) Medical record. Medical record means all or any portion of the medical record as requested by the medical review agent;
   12. (L) Medical review agent. Medical review agent means the state’s representative who is authorized to make decisions about admission certifications and validation reviews;
   13. (M) Medically necessary. Medically necessary means an inpatient hospital service that is consistent with the recipient’s diagnosis or condition and is in accordance with the criteria as specified by the department;
   14. (N) Nurse reviewer. Nurse reviewer means a person who is employed by or under contract with the medical review agent and who is licensed to practice professional nursing in Missouri;
   15. (O) Pertinent information. Pertinent information means any information that the physician, hospital or recipient feels may justify or qualify the hospitalization;
   16. (P) Physician reviewer. Physician reviewer means a physician who is a peer of the admitting/attending physician or who specializes in the type of care under review. Exceptions will be made only if the efficiency or effectiveness of the review would be compromised, but in every situation the review will be performed by a physician;
   17. (Q) Readmission. Readmission means an admission that occurs within fifteen (15) days of a discharge of the same recipient from the same or a different hospital. The fifteen (15)- day period does not include the day of discharge or the day of readmission;
   18. (R) Recipient. Recipient means a person who has applied and been determined eligible for Medicaid benefits;
   19. (S) Reconsideration. Reconsideration means a review of a denial or withdrawal of admission certification;
   20. (T) Required information. Required information means the information to be provided by the physician or hospital to obtain a preadmission or postadmission certification, which includes recipient, physician and hospital identifying information, admission date, admission diagnosis, procedures, surgery date, indications for inpatient setting and plan of care;
   21. (U) Transfer. Transfer means the movement of a recipient after admission from one

2. (1) hospital directly to another or within the same facility;

   1. (V) Urgent admission. Urgent admission means a case which requires prompt admission to the hospital to prevent deterioration of a medical condition from an urgent to an emergency situation; and
   2. (W) Validation review. Validation review means a review conducted after admission certification has been approved. The review is focused on validating the admitting information and confirming the determination of medical necessity of the admission.

3. (2) All admissions of Medicaid recipients to Medicaid participating hospitals in Missouri and bordering states are subject to admission certification procedures and validation review with the following exceptions as specified in Missouri Medicaid provider manuals or bulletins:

   1. (A) Admissions of recipients enrolled in a Medicaid prepaid health plan;
   2. (B) Admissions of recipients eligible for both Part A Medicare and Medicaid;
   3. (C) Admissions for deliveries;
   4. (D) Admissions for newborns; and
   5. (E) Admissions for certain pregnancyrelated diagnoses. The diagnoses codes for deliveries, newborns and pregnancy-related conditions are as published in the ICD9-CM (Internal Classification of Diseases, 9th Revision, Clinical Modification). Admissions with diagnoses codes for missed abortion, pregnancy with abortive outcome and postpartum condition or complication will continue to require admission certification and validation review.
4. (3) The admission certification procedure and validation review will be performed by a medical review agent. The confidentiality of all information shall be adhered to in accordance with section 208.155, RSMo and Title 42, Code of Federal Regulations part 431, subpart F. The medical review agent’s decisions related to certification or noncertification of Medicaid admissions are advisory in nature. The department is the final payment authority. The medical review agent’s review decisions will be used as the basis for Medicaid reimbursement.

5. (4) The types of certification and review include:

   1. (A) Preadmission certification of nonemergency (elective) admissions of Medicaid recipients with established eligibility on date of admission;
   2. (B) Postadmission certification of emergency and urgent admissions of Medicaid recipients with established eligibility on date of admission;

   3. (C) Retrospective certification if the following occurs:

      1. 1. The request for preadmission or

postadmission certification is not obtained in a timely manner as stated in subsection (5)(A) or (B); or

1. 2. Recipient eligibility is not established

on or by date of admission;

1. (D) Retrospective validation review of sample cases to assure information provided during admission certification is substantiated by documentation in the medical record; and
2. (E) A review of quality will be performed for those cases selected as part of the focused and random validation and Certification of Need Samples. Potential quality issues that represent a minor or less than serious risk to a patient will not be pursued. However, potentially serious quality issues will proceed through three (3) levels of specialty physician review if the issue is upheld by the physician reviewers at the first and second level physician review.

1. (5) Time requirements for the certification procedures are as follows:

   1. (A) Physician or hospital notification to the medical review agent of a planned elective admission must occur no later than two (2) full working days prior to the date of the planned admission;
   2. (B) Physician or hospital notification to the medical review agent of the occurrence of an emergency or urgent admission is required by the end of the first full working day after the date of the actual admission;
   3. (C) The medical review agent will determine the medical necessity of admissions specified in subsections (4)(A) and (B) within two (2) working days after receipt of all required information from the physician or hospital;
   4. (D) The hospital shall submit, at its own expense, the recipient’s medical record to the medical review agent for retrospective certification cases specified in subsection (4)(C). Retrospective certification requests must be submitted in a reasonable period of time so as to allow the hospital to meet the claims timely filing requirements of 13 CSR 70-3.100; and
   5. (E) After receipt of all the required medical record information, the medical review agent will determine medical necessity of admissions specified in subsection (4)(C) within fifteen (15) working days if the criteria in section (6) are met or within twentyfive (25) working days if the case is referred to a physician reviewer. 13 CSR 70-15

2. (6) The criteria to be used in the admission certification and validation review are as follows:

   1. (A) The severity of illness/intensity of service (SI/IS) criteria set includes adult and pediatric criteria for general medical care admissions;
   2. (B) Supplemental criteria sets are included for adult and child psychiatric care, rehabilitation care and alcohol/drug abuse treatment;
   3. (C) Ambulatory procedure screening criteria is used in screening admissions for procedures on the Medicaid outpatient surgery list; and
   4. (D) Urgent/emergency criteria are used as guidelines for determination of type of admission and are defined in section (1).

3. (7) The admission certification procedure is as follows:

   1. (A) Certification requests can be made in the following manner:

      1. 1. For preadmission and postadmission

certification, the physician or hospital contacts the medical review agent to provide the required information to obtain certification; or

1. 2. For retrospective certification, the

hospital submits, at its own expense, the recipient’s medical record to the medical review agent to obtain certification which is to include the emergency room record; history and physical; any operative, pathology or consultation reports; the first three (3) days of physician orders, progress notes, nurses’ notes, graphic vital signs, medication sheets and diagnostic testing results;

1. (B) Initial screening of information is conducted by nurse reviewers using the criteria in section (6) as appropriate to the case under review;
2. (C) If the medical information submitted regarding the patient’s condition and planned services meets the applicable criteria in section (6), the approval decision and a unique certification number are communicated to the physician and hospital;
3. (D) If the applicable criteria in section (6) are not met, the nurse reviewer refers the case to a physician reviewer for a medical necessity determination. The physician reviewer is not bound by any criteria and makes the determination based on medical facts in the case using his/her medical judgment;
4. (E) If the physician reviewer approves the admission, the approval determination and unique certification number are communicated to the physician and hospital;

5. (F) The physician will be contacted prior to a denial determination and allowed the opportunity to provide additional information. This additional information will be considered by the physician reviewer prior to a determination to approve or deny admissions. Determination decisions will be communicated as follows:

   1. 1. If the admission is approved, the

approval determination and unique certification number are communicated to the physician and hospital; and

1. 2. Denial determinations are communi-

cated to the physician, hospital and recipient;

1. (G) The physician, hospital or recipient who is dissatisfied with an initial denial determination is entitled to a reconsideration by the medical review agent as outlined in section (8); and
2. (H) If inpatient admission is approved and surgery is planned, day of surgery admission will be required unless the physician reviewer approves a preoperative day for evaluating concurrent medical conditions or other risk factors.

1. (8) Reconsideration Requests. The medical review agent’s denial decisions relate to medical necessity and appropriateness of the inpatient setting in which services were furnished or are proposed to be furnished. The procedure to request reconsideration of an initial denial determination is as follows:

   1. (A) Time Requirements.

      1. 1. To request a reconsideration for a

patient prior to admission or for a patient still in the hospital, the provider should telephone a request to the medical review agent. In either of these situations, the request for reconsideration must be received within three (3) working days of receipt of the written denial notice. In order to expedite the process, the provider must indicate that this is a request for a reconsideration. The medical review agent will complete the reconsideration review and issue a determination within three (3) working days of receipt of the request and all pertinent information; and

1. 2. If the patient has been discharged

from the hospital, the provider must submit a request for reconsideration in writing or by facsimile (FAX). This reconsideration cannot be requested by telephone. The request must be made within sixty (60) calendar days of receipt of the written denial notice. The medical review agent will complete the reconsideration review within thirty (30) days after receipt of the request for reconsideration, medical records and all pertinent information. A written notice will be issued to the recipient, physician and hospital within three (3) days after the reconsideration is completed;

1. (B) The reconsideration shall consist of a review of all medical records and additional documentation submitted by any one of the parties to the initial denial notice;
2. (C) The reconsideration will be conducted by a physician reviewer who has had no previous involvement in the case;
3. (D) Reconsideration determination by the medical review agent is the final level of the review for the provider. The division will accept the medical review agent’s decision; and
4. (E) If the recipient disagrees with a reconsideration denial by the medical review agent, s/he has the right to a fair hearing under sections 208.080, RSMo and 208.156, RSMo.

1. (9) Validation Sample of Approved Admissions.

   1. (A) A quarterly validation sample of approved admissions will be selected to ensure that the information provided during the certification process is substantiated by documentation and clinical findings in the medical record.
   2. (B) The sample size is a random sample of five percent (5%) of the medical review agent’s certified admissions.
   3. (C) For admissions subject to review, the medical review agent will request medical records. Providers have thirty (30) calendar days from the date of request to submit documentation. At rates determined by the medical review agent, provider costs associated with submission of requested documentation will be reimbursed. Records not received within the thirty (30) days will result in the admission being denied.
   4. (D) Admission certification is not a guarantee of Medicaid payment. If the information provided during the certification process cannot be validated in the medical record by a nurse reviewer using the criteria in section (6), or was false, misleading or incomplete, the case will be referred to a physician reviewer for a medical necessity determination. The physician reviewer is not bound by any criteria and makes the determination based on medical facts in the case using his/her medical judgment.
   5. (E) The physician or hospital will be allowed an opportunity to respond to a proposed denial prior to issuance of a final denial notice.
   6. (F) If the physician reviewer determines the admission was not medically necessary, a denial notice will be issued to all parties. Reconsideration procedures in section (8) apply to this review.
   7. (G) A validation review determination of denial will result in recovery of Medicaid payments in accordance with 13 CSR 70- 3.030. Overpayment determinations may be appealed to the Administrative Hearing Commission within thirty (30) days of the date of the notice letter if the sum in dispute exceeds five hundred dollars ($500).
   8. (H) Review of the quality of care will also be performed on the validation review sample for admissions on or after August 1, 1996. Potentially serious quality of care issues identified by the nurse reviewer will be referred to a physician of the medical review agent.

2. (10) As specific in relation to administration of the provisions of this rule and not otherwise inconsistent with recipient liability as determined under provisions of 13 CSR 70- 4.030, recipient liability issues for admission certification and validation review are as follows:

   1. (A) The recipient is liable for inpatient hospital services in the following circumstances:

      1. 1. When the preadmission request for

certification is denied and the recipient is notified of the denial but the recipient chooses to be admitted, s/he is liable for all days;

1. 2. When a postadmission request for

certification of an admission is denied, the recipient is liable for those days of inpatient hospital service provided after the date of the notification to him/her of the denial;

1. 3. When the recipient’s eligibility was

not established on or by the date of admission and the request for certification is denied, the recipient is liable for all days; and

1. 4. When the recipient has signed a writ-

ten agreement with the provider indicating that Medicaid is not the intended payer for the specific item or service, s/he is liable for all days. The agreement must be signed prior to receiving the services. In this situation, the recipient accepts the status and liabilities of a private pay patient in accordance with 13 CSR 70-4.030; and

1. (B) The recipient is not liable for inpatient hospital services in the following circumstances:

   1. 1. When the provider fails to comply

with preadmission certification requirements, the recipient is not liable for any days;

1. 2. When a postadmission request for

certification of an admission is denied, the recipient is not liable for those days of inpatient hospital service provided prior to and including the date of the notification to him/her of the denial; and

1. 3. When the medical review agent per-

forms a validation review as provided in section (9) of this rule and determines an admission was not medically necessary for inpatient services, the recipient is not liable for any days. (11) Continued stay reviews will be performed for all other fee-for-service Missouri Medicaid recipients subject to admission certification to determine that services are medically necessary and appropriate for inpatient care. The continued stay review procedure is as follows:

1. (A) When extended hospitalization is indicated beyond the initial length of stay assigned by the medical review agent, the hospital and attending physician are required to provide additional medical information to warrant the continued hospital stay as well as request the number of additional days needed;
2. (B) The nurse reviewer applies the severity of illness/intensity of services (SI/IS) criteria as described in section (6) of this rule. If the case meets intensity of services criteria, an appropriate extension is assigned up to the length-of-stay (LOS) seventy-fifth percentile;
3. (C) A physician will review cases when continued stay is requested beyond the seventy-fifth percentile. The physician reviewer shall approve or deny the continued stay days;
4. (D) The requesting physician and hospital are notified of the review decision as stated in section (7) of this rule; and
5. (E) Sections (8)–(10) of this rule apply to continued stay reviews.

1. (12) Continued stay reviews will be performed for diagnosis relating to alcohol and drug abuse, ICD 9-CM diagnosis codes in the ranges of 291, 292, 303, 304 and 305 for admission of July 15, 1991, and after that to determine that services are medically necessary and appropriate for inpatient care. The continued stay review procedure for alcohol and drug abuse detoxification services is as follows:

   1. (A) At the time of admission certification, as described in section (7) of this rule, the hospital or attending physician shall specify the anticipated medically necessary length-ofstay;
   2. (B) If the applicable criteria in section (6) of this rule is met, the nurse reviewer shall assign a number of days not to exceed three

2. (3) days;

   1. (C) If an extension of services is required, the hospital or attending physician shall contact the medical review agent to request additional days for inpatient hospital care. If the applicable criteria in section (6) of this rule is met, the nurse reviewer shall assign a total length-of-stay days not to exceed five (5) days;
   2. (D) If either the applicable criteria in section (6) of this rule is not met or the total length-of-stay exceeds five (5) days, the case shall be referred to a physician reviewer. The physician reviewer is not bound by the criteria in section (6) of this rule and makes the determination based on medical facts in the case using his/her medical judgment. The physician reviewer shall approve or deny the admission or continued stay days;
   3. (E) The physician and hospital are notified of the review decision as stated in section (7) of this rule; and
   4. (F) Sections (8)–(10) of this rule apply to continued stay reviews.

3. (13) Large case management will be performed for fee-for-service recipients with potentially catastrophic conditions whenever specific trigger diagnoses or other qualifying events are met. MC+ health plans eligible under the state’s reinsurance plan for additional reimbursement of eighty percent (80%) of the plan’s payment for inpatient days which exceed fifty thousand dollars ($50,000) in an MC+ enrollee’s plan year are subject to the medical review agent’s monitoring of the plan’s large case management intervention.

   1. (A) Large case management procedures for fee-for-service recipients are as follows:

      1. 1. Preadmission review nurses identify

patients who may qualify and benefit from case management, and refer to a case manager of the medical review agent. Cases include but are not limited to the following:

1. A. Patients with high costs or antici-

pated high costs; or

1. B. Patients with repeated admissions

or unusually long lengths-of-stay; or

1. C. Patients who encounter significant

variances from the intervention or from expected outcomes associated with a clinical path; or

1. D. Patients who meet one (1) or more

of the indicators on the Trigger Diagnosis/Qualifying Events list;

1. 2. The medical review agent will com-

plete an initial screening which will include a review of the medical information, and interviews with the health care providers and patient if needed or feasible;

1. 3. An in-depth assessment will be con-

ducted, which will include evaluation of the patient’s health status, health care treatment and service needs, support system, home environment and physical and psychosocial functioning. The assessment will be used to recommend one (1) of the following:

1. A. Reassessment later; or
2. B. No potential for case management;

or

1. C. Active monitoring in anticipation

of a future plan for alternative treatment; or

1. D. An alternative treatment plan is

indicated;

1. 4. If an alternative treatment plan is

indicated, the medical review agent will col- 13 CSR 70-15

laborate with the patient’s attending physician to develop an alternative treatment plan. The attending physician is responsible for implementation of the alternative treatment plan; and

1. 5. The medical review agent will moni-

tor and assess the effectiveness of the case management and will report to the state.

1. (B) Large case management procedures for MC+ cases reaching the fifty thousand dollar ($50,000) reinsurance cap are as follows:

   1. 1. The MC+ health plan case manager

or established liaison will be responsible for notifying the medical review agent as soon as a potential case management patient is identified. The medical review agent must be notified of MC+ enrollees who reach a threshold of forty thousand dollars ($40,000), and provide information needed for the initial screen;

1. 2. The medical review agent will com-

plete an initial screening which will include a review of the medical information, patient status, current plan of care, hospital discharge summaries, and other records as appropriate, to be supplied by the health plan;

1. 3. An in-depth assessment will be con-

ducted, which will include evaluation of the patient’s health status, health care treatment and service needs, support system, home environment and physical and psychosocial functioning. The assessment will be used to recommend one (1) of the following:

1. A. Reassessment later; or
2. B. No potential for case management;

or

1. C. Active monitoring in anticipation

of a future plan for alternative treatment; or

1. D. An alternative treatment plan is

indicated;

1. 4. If an alternative treatment plan is

indicated, the medical review agent will collaborate with a physician representative from the health plan’s Utilization Review/Quality Assessment (UR/QA) Committee to discuss and develop an alternative treatment plan. The medical review agent will recommend an alternative treatment plan to the health plan;

1. 5. The medical review agent will moni-

tor and assess the effectiveness of the case management and will report to the state; and

1. 6. The medical review agent will moni-

tor each day of inpatient hospital care provided subsequent to the fifty thousand dollar ($50,000)-threshold for appropriateness and acute level of care.

1. (14) Psychiatric admissions for Medicaid recipients twenty-one (21) and over enrolled in a MC+ health plan who have exceeded the thirty (30) inpatient days/twenty (20) outpatient days limitation of behavioral health care in a plan year will be subject to a retrospective postpayment utilization/quality of care review by the medical review agent. The objectives of this review focus are to collect data on potentially medically unnecessary inpatient days of care to assist the division in projecting potential expenditures that could be made available for outpatient care, assuring that inpatient care is of acceptable quality, identify social or placement problems when post-hospital psychiatric services are needed, and monitor and report health plan compliance to notification requirements for enrollees meeting the thirty/twenty (30/20) cap.

AUTHORITY: section 208.201, RSMo 1994.* Emergency rule filed Oct. 20, 1989, effective Nov. 1, 1989, expired Feb. 28, 1990. Original rule filed Nov. 2, 1989, effective Feb. 25, 1990. Amended: Filed June 18, 1991, effective Jan. 13, 1992. Amended: Filed July 2, 1992, effective Feb. 26, 1993. Amended: Filed July 1, 1996, effective Feb. 28, 1997. *Original authority 1987.