1. (a) The Texas Health and Human Services Commission (Commission) uses physician-developed and physician-approved inpatient hospital screening criteria. The criteria include Indications for Hospitalization (IH) and Treatment (T) criteria. Nonphysician reviewers use the criteria as guidelines for the initial approval or for the referral of inpatient reviews for medical necessity decisions. If the IH or T criteria are not met, or if the nonphysician reviewer has any questions concerning the appropriateness of coding or quality of care, the nonphysician reviewer will refer the medical record to a physician consultant under contract with the Commission for a decision. Even if the IH and T criteria are met, the physician consultant may determine that an inpatient admission was not medically necessary and the Commission will issue an admission denial. A physician consultant may determine that an inpatient admission was not medically necessary if a physician admitted a patient in observation status and the patient was discharged within twenty-four hours from that outpatient status.
2. (b) For the purposes of the TMRP, TEFRA, and LoneSTAR Select II Contract reviews, medical necessity means that the patient has a condition requiring treatment that can be safely provided only in the inpatient setting.

Source Note:The provisions of this §371.204 adopted to be effective June 14, 1989, 14 TexReg 2624; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308; amended to be effective March 30, 2003, 28 TexReg 2481.