Inpatient Hospital Services: Quality Assurance

The designated QIO must prepare, distribute, and maintain a provider manual that is periodically updated. The manual must include the following: (7-1-26) 01. QIO Information. The QIO's policies, criteria, standards, operating procedures, and forms for performing: preadmission monitoring, assessment reviews, continued stay requests, and requests for retroactive medical reviews. (7-1-26) 02. Department Provisions. Department-selected diagnoses and procedures in which a hospital will request preauthorization of an admission, transfer, or continuing stay. (7-1-26) 03. Approval Timeframe. A provision that the QIO will inform the hospital of a certification within five (5) days, or other time frame as determined by the Department, of an approved admission, transfer, or continuing stay. (7-1-26) 04. Method of Notice. The method of notice to hospitals of QIO denials for specific admissions, IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 080 Page 48 transfers, continuing stays, or services rendered in post-payment reviews. (7-1-26) 05. Procedural Information. The procedures that providers or participants will use to obtain reconsideration of a denial by the QIO prior to appeal to the Department. Such requests for reconsideration by the QIO must be made in writing to the QIO within one hundred eighty (180) days of the issuance of the “Notice of Non- Certification of Hospital Days.” (7-1-26) 076. – 079. (RESERVED)