PURPOSE: This rule establishes the basis on which hospitals furnishing inpatient care to Medicaid recipients are audited to determine that admissions/lengths of stay were medically necessary, of appropriate duration and setting, and in compliance with Medicaid rules and policies.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

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

   1. (A) Acute care means medical care delivered on an inpatient basis requiring continuous direction by a physician;
   2. (B) Adequate documentation means documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty;

   3. (C) Adequate hospital inpatient medical records are records which are of the type and in a form required of good medical practice and containing:

      1. 1. Patient identification data;
      2. 2. Medical history of the patient;
      3. 3. Report of a relevant physical exami-

nation;

1. 4. Diagnostic and therapeutic orders;
2. 5. Evidence of appropriate informed

consent. When consent is not available, the reason shall be entered in the record;

1. 6. Clinical observations, including

results of therapy;

1. 7. Reports of procedures, tests and the

results; and

1. 8. Conclusions at termination of hospi-

talization or evaluation/treatment;

1. (D) Medical history means chief complaint; details of present illness, including assessment of the patient’s emotional, behavioral and social status; relevant past, social and family histories; and inventory by body systems where necessary for diagnosis and treatment;
2. (E) Medically necessary inpatient services means medical treatment for health reasons requiring continuous direction by a physician in an acute care setting;
3. (F) Nursing facility care means a level-ofcare which can be provided in a nursing facility either by or under the supervision of licensed nursing personnel for persons requiring personal care, observation, basic health care, supervision of diets, storage, distribution or administration of medications; or treatments prescribed by a licensed physician not on an acute-care level;
4. (G) Pertinent information means information sufficient to identify the patient, to support the diagnosis and to justify the treatment; and
5. (H) Physician reviewer means physicians currently practicing in Missouri under contract to the division to perform peer review.

1. (2) Medicaid-participating hospitals in Missouri and bordering states are subject to desk or on-site audit procedures as outlined 13 CSR 70-15

in this rule. The division or its representatives will conduct audits to determine medically necessary services, appropriateness of setting and program compliance for admissions and continued days of stay. Audits may include any the following areas:

1. (A) Admission and continued days-of-stay audits for admissions of deliveries and newborns, and diagnosis exempt from admission certification; and
2. (B) Continued days-of-stay audits, beginning with the day after admission, which require admission certification as required by 13 CSR 70-15.020.

1. (3) At the discretion of the division, the audit may include, but is not limited to, any of the following:

   1. (A) An examination by division personnel of—

      1. 1. Closed medical records of all

Medicaid recipients;

1. 2. Open and active/open medical

records of all Medicaid recipients;

1. 3. The current and all past utilization

review plans;

1. 4. All minutes of utilization review com-

mittee meetings which concern Medicaidrecipient stays;

1. 5. Utilization review documents which

concern Medicaid-recipient stays;

1. 6. Medical/psychological care evalua-

tion/quality assurance studies completed and in progress; and

1. 7. Plans of care required by a federal or

state authority(ies); and

1. (B) Discussions with hospital staff and employees regarding hospital policies and procedures related to medical documentation and claims of Medicaid recipients.

1. (4) The severity of illness/intensity of service (SI/IS) criteria are used as screening criteria for medical review audits. The SI/IS criteria filed with this rule and incorporated in this rule includes adult and pediatric criteria for general medical care. Supplemental criteria sets are included for adult and child/adolescent psychiatric care, rehabilitation care and alcohol/drug abuse treatment. The SI/IS criteria and supplemental sets are criteria used by the division for admission certification elaborated in 13 CSR 70-15.020(6).

2. (5) The medical review audit procedure may include the following:

   1. (A) A notice letter of the audit sent to the hospital administrator with the following time requirements:

      1. 1. The hospital receives fifteen (15) cal-

endar days’ notice prior to the date upon which an on-site audit is to begin; or

1. 2. The hospital has thirty (30) calendar

days from the date of notice to furnish medical records for desk audits. A single extension not to exceed fifteen (15) calendar days may be granted upon the request of the hospital. Records not received timely will automatically result in the services being denied;

1. (B) An initial screening of the medical record information is performed by nurse reviewers using the criteria in section (4) as appropriate to the case;
2. (C) If the medical record documentation regarding the patient’s condition and planned services meet the applicable criteria in section (4), the services are approved as medically necessary;
3. (D) If the applicable criteria in section (4) are not met, the nurse reviewer refers the case to a physician reviewer for a medical necessity and appropriateness of setting determination. The physician reviewer is not bound by criteria used. The physician reviewer uses his/her medical judgment to make a determination based on the documented medical facts in the record;
4. (E) If the physician reviewer denies the admission or continued days of stay, a preliminary denial notice is mailed to the attending physician and hospital;
5. (F) The attending physician and hospital have fifteen (15) working days from the date of notice to send in additional documentation;
6. (G) The physician reviewer examines the medical record and the additional documentation prior to a determination to approve or deny the admission or continued days of stay. The determination made by the physician reviewer completes the final level of review; and
7. (H) A written report of the physician reviewer’s determinations, as approved by the division, is issued.

1. (6) A policy compliance audit can be performed to determine conformity with written and published policies and procedures of the Medicaid inpatient hospital program as contained in provider manuals and bulletins.
2. (7) A utilization review audit can be performed to determine compliance with the hospital’s utilization review plan applicable to the Medicaid program and defined in federal regulation Title 42 CFR 456 subparts C and D, and 42 CFR 482.30.
3. (8) All pertinent and complete medical record documentation and utilization review records must be made available at the time of the review and copies provided, if requested, by the hospital to the division. The review and decision are based upon the documents provided at the time of review contained in the medical record for the specific date of admission.
4. (9) Payment for requested copies will be reimbursed at ten cents (10¢) per page by submitting to the division an invoice indicating the number of pages per record. No additional reimbursement will be made for postage. Copies must be legible.

5. (10) Hospitals are notified by the division if an adjustment of Medicaid payments is required as a result of audit findings. The following Medicaid policies apply for calculation of Medicaid payment:

   1. (A) Medicaid shall reimburse nursing facility care provided in the inpatient hospital setting in accordance with 13 CSR 70- 15.010(11);
   2. (B) No Medicaid payment will be made on behalf of any recipient who is receiving inpatient hospital care and is not in need of either inpatient or nursing facility care. No payment will be made for outpatient services rendered on an inpatient basis; or
   3. (C) Medicaid does not pay for admissions or continued days of stay for social situations, placement problems, court commitments or abuse/neglect without medical risk.
6. (11) Overpayment determinations may be appealed to the Administrative Hearing Commission within thirty (30) days of the date of notice letter if the sum in dispute exceeds five hundred dollars ($500).

AUTHORITY: sections 208.153, RSMo Supp. 1991 and 208.201, RSMo Supp. 1987.* This rule was previously filed as 13 CSR 40- 81.162. Original rule filed May 3, 1985, effective Sept. 1, 1985. Amended: Filed Nov. 15, 1988, effective Feb. 11, 1989. Amended: Filed April 4, 1989, effective June 29, 1989. Rescinded: Filed Nov. 2, 1989, effective Jan. 26, 1990. Emergency rule filed June 4, 1990, effective June 28, 1990, expired Oct. 25, 1990. Readopted: Filed June 4, 1990, effective Nov. 30, 1990. *Original authority: 208.153, RSMo 1967, amended 1973, 1989, 1990, 1991 and 208.201, RSMo 1987.