Utilization review program for inpatient psychiatric services for clients under age twenty-one or age sixty-five or over

twenty-one or age sixty-five or over (a) The department's Utilization Review Program conducts utilization review activities for services delivered by the inpatient psychiatric hospital to clients where the Medical Assistance Program has been determined to be the appropriate payer. (b) To determine that inpatient psychiatric services or admissions are medically necessary and medically appropriate, the department may: (1) require preadmission review or prior authorization of each inpatient psychiatric hospital admission, including a certificate of need review, for clients under age twenty-one, unless the department notifies the providers that a specific admission, diagnosis, or procedure does not require such authorization; and (2) perform retrospective reviews at the department's discretion which may be a random or targeted sample of the admissions and services delivered. The review may be focused on the appropriateness, necessity, or quality of the health care services provided. (c) If the department decides to impose prior authorization or preadmission review requirements, all effected providers shall be notified at least thirty days in advance of date of implementation. (d) All claims for payment for admission and all days of stay and services that are provided shall be documented. Lack of said documentation itself may be adequate ground for the department, in its discretion, to deny or recoup payment for the admission for some or all of the days of stay or services provided. (e) The department shall conduct medical review and inspections of care in psychiatric hospitals.