1. (a) The bureau shall conduct utilization reviews for continued placement as described in this section.

2. (b) For individuals approved to receive short-term skilled nursing care or rehabilitative services, the following shall apply:

   1. (1) The initial authorization shall be for up to 30 days;
   2. (2) The individual shall be eligible for up to 2 additional 30-day authorization periods, based on a utilization review conducted by the bureau;
   3. (3) The NF shall submit to the bureau a completed “Utilization Review Form”, incorporated by reference in He-E 802.19(b), and any supporting documentation no later than 14 days prior to the end of the current authorization period; and
   4. (4) The bureau shall determine continued placement authorization if, based on the documentation in (3) above, the eligibility criteria in He-E 802.04(b) are met.

3. (c) For individuals approved to receive atypical non-behavioral long-term care services, the following shall apply:

   1. (1) The initial authorization shall be for one year;
   2. (2) The individual shall be eligible for additional one-year authorization periods, based on a utilization review conducted by the bureau;
   3. (3) The NF shall submit to the bureau a completed assessment pursuant to He-E 802.05(a)(1)b. and any supporting documentation no later than 14 days prior to the end of the current authorization period; and
   4. (4) The bureau shall determine continued placement authorization if, based on the documentation in (3) above, the eligibility criteria in He-E 802.04(c) are met.

4. (d) For individuals approved to receive atypical behavioral long-term care services, the following shall apply:

   1. (1) The initial authorization shall be for 6 months;
   2. (2) The individual shall be eligible for an additional 6-month authorization period for a total of one year, after which additional authorization periods shall be for one year, based on a utilization review conducted by the bureau;

   3. (3) The NF shall submit to the bureau, no later than 14 days prior to the end of the current authorization period, a completed “Utilization Review Form”, incorporated by reference in He-E 802.19(b), and the following supporting documentation:

      1. a. A psychological evaluation;
      2. b. A behavioral plan;
      3. c. The bureau’s “Memory and Behavior Checklist”, incorporated by reference in He-E 802.19(c); and

      4. d. A behavior summary which:

         1. 1. Includes the same information as the bureau’s “Behavior Summary Report”, incorporated by reference in He-E 802.19(d); and
         2. 2. Describes the recommended transition plan from the behavioral unit;
   4. (4) The supporting documentation in (3) above shall have been completed no earlier than 30 days prior to its submission;
   5. (5) After one year, in addition to the documentation in (3) above, the facility shall also submit to the bureau a completed assessment pursuant to He-E 802.05(a)(1)b.; and
   6. (6) The bureau shall determine continued placement authorization if, based on the documentation in (3)-(5) above, the eligibility criteria in He-E 802.04(d) are met.

5. (e) For individuals authorized for placement in a swing bed, the following shall apply:

   1. (1) For residents with a temporary placement, the requirements in (b) above shall apply; and

   2. (2) For residents with a pending placement, the following shall apply:

      1. a. The initial authorization shall be for 30 days;
      2. b. The individual shall be eligible for additional 30-day authorization periods, based on a utilization review conducted by the bureau;
      3. c. The NF shall submit to the bureau a completed “Utilization Review Form”, incorporated by reference in He-E 802.19(b), and any supporting documentation no later than 14 days prior to the end of the current authorization period; and
      4. d. The bureau shall determine continued placement authorization if, based on the documentation in c. above, the eligibility criteria in He-E 802.04(e) are met.
6. (f) If the NF fails to submit timely utilization review documentation and supporting documentation in accordance with this section, the authorization for services and the payment for services provided shall end.
7. (g) When, as a result of utilization review, the medical condition of a resident in a specific placement no longer meets the criteria specified in He-E 802.04 for the specific placement, a notice of the determination and the right to request an appeal shall be sent to the resident and the NF, pursuant to He-E 802.05(h).

Source. #7751, eff 8-17-02, EXPIRED: 8-17-10 New. #9786, INTERIM, eff 9-20-10; ss and renumbered by #9888-A, eff 3-19-11, EXPIRED: 3-19-19 (formerly He-E 802.19) New. #12741, INTERIM, eff 3-20-19, EXPIRED: 9-16-19 New. #13130, eff 10-30-20