1. (a) For all Medicaid admissions identified for review, the TEFRA review process includes, but is not limited to, the following:

   1. (1) admission review, which is a determination of the medical necessity of the admission;
   2. (2) continued stay review, which is a determination of the medical necessity of each day of stay;
   3. (3) quality of care review, which is an assessment of the quality of care provided to determine if it meets generally accepted standards of medical and hospital care practices or puts the patient at risk of unnecessary injury or death. Quality of care review includes the use of discharge screens and generic quality screens; and
   4. (4) emergency service review, which consists of verifying that the emergency principal diagnosis billed and paid, is substantiated in the medical record. The principal diagnosis is verified as stated in the normal DRG validation process in §41.104(a)(2) of this title (relating to Texas Medical Review Program (TMRP) Review Process). If the admission is to a noncontracted hospital in the Medicaid Selective Contracting Program or any other hospital approved for emergency inpatient services only and the process results in a change to the principal diagnosis that consequently designates the admission as nonemergency, all monies paid shall be recouped by the Texas Department of Health (department) or its contractor.
2. (b) Staff will review the complete medical record to make decisions concerning the medical necessity of the admission, continued stay, and quality of care. The complete medical record must include, but is not limited to: medical/surgical history and physical examination, discharge summary, physician's progress notes, physicians' orders, lab reports, x-ray reports, operative reports, pathology reports, nurses' notes, medication sheets, vital signs sheets, therapy notes, specialty consultation reports, special diagnostic and treatment records.
3. (c) If the complete medical record is not available or is not made available during the review, a preliminary technical denial will be issued. The facility will be notified and allowed 60 days, after receipt of the notification, to provide the complete medical record. If the complete medical record is received within the 60 days, a final technical denial is not issued and the medical record is reviewed. If the complete medical record is not received within the 60 days, a final technical denial is issued, and payment is recouped. Medical records not received within the 60 days shall be denied review on the merits, and any claim the hospital may have to the Medicaid funds at issue shall be barred. Extensions of time will not be granted for the filing of a medical record beyond the 60 days.
4. (d) A practicing physician consultant shall make all decisions regarding any aspect of the review process that involves determining medical necessity, cause of readmission, or appropriateness of setting regarding the service provided. In the event the practicing physician consultant determines the services were not medically necessary; should have been provided in the first admission; or were not provided in the appropriate setting, the hospital is notified in writing of that decision and appropriate action shall be taken.

Source Note:The provisions of this §371.210 adopted to be effective June 14, 1989, 14 TexReg 2624; amended to be effective February 1, 1991, 16 TexReg 232; amended to be effective January 1, 1993, 17 TexReg 8457; transferred effective September 1, 1993, as published in the Texas Register January 28, 1994, 19 TexReg 589; amended to be effective November 22, 1995, 20 TexReg 9274; transferred effective September 1, 1997, as published in the Texas Register February 18, 2000, 25 TexReg 1308.