Screening Program for Chronic-Disease and Rehabilitation Hospitals

(A) Introduction. The screening program applies to all in-state and out-of-state chronic-disease and rehabilitation hospitals, except those participating in a managed-care program for all inpatients (see 130 CMR 435.402). The screening program described in 130 CMR 435.408 is intended to ensure that medical and nursing services are medically necessary. The MassHealth agency pays for chronic-disease and rehabilitation hospital services only when the MassHealth agency or its agent determines, pursuant to a screening, that such services are medically necessary and authorizes such services prior to admission or conversion. (B) Screening. (1) To initiate admission or conversion screening, the hospital must telephone the MassHealth agency or its agent prior to the proposed admission or anticipated conversion and must: (a) describe the medical condition that necessitates a chronic-disease or rehabilitation hospital admission or continued stay; and (b) state the anticipated length of stay. (2) The MassHealth agency or its agent applies the level-of-care criteria stated in 130 CMR 435.409 or 435.410, whichever is applicable, to determine the medical necessity of the proposed admission or continued stay, as well as the anticipated length of stay. (3) If the MassHealth agency or its agent determines that the proposed admission or continued stay is not medically necessary and denies authorization for such admission or continued stay, the hospital may appeal the denial as stated in 130 CMR 435.408(C). (4) If the MassHealth agency or its agent determines that the proposed admission or continued stay is medically necessary, the admission or continued stay will be authorized with a specified, approved length of stay, and the hospital will be issued a preapproved screening number to be used when billing for the hospital stay. Approval may be given by telephone; however, authorization for payment is contingent upon receipt of written authorization from the MassHealth agency or its agent. The MassHealth agency will not pay the hospital for any costs incurred after the expiration of the specified, approved length-of-stay period. (5) Prior to the expiration of the approved length of stay, the hospital or attending physician may request an extension of the length of stay if the member continues to require hospitalization beyond the approved period. The Division or its agent will perform a concurrent review when such a request is made. Such request is subject to the screening program regulations in 130 CMR 435.408. (6) The Division or its agent will send written notification of denial or written notification of authorization for payment and a preapproved screening number to the hospital within two working days after the completion of the screening. (C) Review of Screening Decisions. (1) If the Division or its agent determines that a hospital admission or continued stay is not medically necessary, the member, the referring or attending physician, or the hospital on behalf of the member, may verbally request reconsideration of the Division's determination. Requests for reconsideration must be made to the Division or its agent and will result in referral of the case to a physician consultant for decision within two working days after the date of the request. (2) If the physician consultant determines that the hospital admission or continued stay is not medically necessary, the member, the referring or attending physician, or the hospital may request further review: (a) by written request to the Division or its agent within seven calendar days after receipt of notice of the initial screening decision. This request must include all supporting documentation to justify the request for admission or continued stay. The Division or its agent will issue a final decision by written notice to the hospital, the member, and the referring or attending physician within two working days after the date the Division receives the request for further review; or (b) by telephone request in order to expedite the review process. An expedited review will be conducted within one working day of receipt by the Division or its agent of the additional information requested during the telephone review. The Division or its agent will issue a final decision by telephone, followed by written notification to the hospital, the member, and the referring or attending physician. (3) The member may appeal a decision to deny an admission or continued stay by requesting a fair hearing before the Board of Hearings in accordance with the provisions governing fair hearings (130 CMR 610.000 et seq.).