1. (a) The Texas Department of Health 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 either the IH or T criteria are not met, or if the nonphysician reviewer has any questions, the medical record will be referred to a physician for a decision. Even if the IH and T criteria are met, the physician reviewer may determine that an inpatient admission was not medically necessary and an admission denial is issued.
2. (b) For the purposes of the TMRP and TEFRA, medical necessity means that the patient has a condition requiring treatment and that the treatment 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.