Utilization Management: Admission Screening for Acute Inpatient Hospitals

(A) Requirements. (1) The MassHealth agency conducts admission screening on elective admissions only. The admitting provider must notify the MassHealth agency, via telephone, fax, or the MassHealth Provider Online Service Center (POSC), at least seven calendar days before a proposed elective admission and provide the information specified in the appendix described in 130 CMR 450.207(B). When the admitting provider cannot notify the MassHealth agency within seven calendar days, the admitting provider must notify the MassHealth agency prior to the elective admission, and no later than 5:00 P.M. on the first day after the decision to admit. The provider must explain to the MassHealth agency why the seven-calendar-day notice requirement was not met. If the MassHealth agency cannot complete the admission-screening process before the scheduled elective admission, when neither the admitting provider nor the acute inpatient hospital has informed the MassHealth agency at least seven calendar days before the admission was scheduled, the provider may be required to reschedule the admission. 2. Administrative Regulations (2) Providers must notify the MassHealth agency of any changes in an approved elective admission as soon as those changes are known, but in any event, before the admission occurs. The MassHealth agency will deny payment if a service or procedure that is provided is not what was proposed and approved, and such procedure, service, or admission is not medically necessary. (3) For postponed admissions, the admitting provider must contact the MassHealth agency and provide updated information no later than 5:00 P.M. on the second business day following the originally planned admission date. (B) Notice of Admission Screening Decisions. The MassHealth agency sends written notice of its decisions to the admitting provider, PCC (if applicable), acute inpatient hospital, and member. (C) Appeal of Admission Screening Decisions. (1) If the MassHealth agency determines that an acute inpatient hospital admission is not medically necessary, the admitting provider or the PCC may request a review of the determination. Such a request must be made in writing and received by the MassHealth agency within seven calendar days after the date of the determination notice. This written request must include all documentation that the provider believes is pertinent for a second review. (2) Providers or members may appeal the MassHealth agency’s decision to deny an elective admission by requesting a hearing before the MassHealth agency’s Board of Hearings. Provider hearings are governed by 130 CMR 450.241 through 450.248. Member hearings are governed by the MassHealth agency’s regulations at 130 CMR 610.000: MassHealth: Fair Hearing Rules. Neither providers nor members are required to exhaust any other appeal rights before requesting a hearing on an admission screening decision; however, providers and members do not have a right to judicial review of an admission screening decision if they fail to exhaust their administrative remedies. (D) Requesting Reconsideration. If the MassHealth agency denies payment for a claim because the admitting provider did not comply with the requirements of 130 CMR 450.208(A), the admitting provider or hospital may request reconsideration of the MassHealth agency's decision by contacting the MassHealth agency in writing within 30 calendar days after the date of the remittance advice on which the claim is denied. The MassHealth agency will process the claim only if the admitting provider or acute inpatient hospital demonstrates that (1) the admission was exempt for one of the reasons described in 130 CMR 450.207(B)(4); (2) the admitting provider, despite reasonable, good-faith efforts to identify all third-party payment sources, was unaware that the patient was a MassHealth member; or (3) the admitting provider complied with all requirements of 130 CMR 450.208(A).