Utilization Management: Prepayment Review for Acute Inpatient Hospitals

(A) Introduction (1) The MassHealth agency conducts prepayment reviews to evaluate acute inpatient hospital admissions for (a) medical necessity, including, but not limited to, the appropriateness of the inpatient admission and any services; (b) the stability of the member at the time of discharge; 2. Administrative Regulations (c) the quality of care provided; and (d) compliance with the MassHealth agency’s billing procedures and requirements. (2) The MassHealth agency will identify each admission to be reviewed by mailing to the acute inpatient hospital a request for selected medical records. (B) Submission Requirements and Time Frames. (1) The acute inpatient hospital must submit the requested medical records to the MassHealth agency. Such medical records must be received by the MassHealth agency within 17 calendar days of the date appearing on the request. If the hospital fails to timely submit the records, the MassHealth agency will deny payment for the admission. (2) If the MassHealth agency concludes that the records submitted are incomplete, it will inform the acute inpatient hospital in writing. The hospital must submit the documents that were missing from the medical record or records to the MassHealth agency. Such documents must be received by the MassHealth agency within 17 calendar days of the date appearing on the MassHealth agency’s notice requesting such information. If the hospital fails to timely submit the documents to complete the medical record, the MassHealth agency will deny payment for the admission. (3) The acute inpatient hospital may request reconsideration of any denials issued in accordance with 130 CMR 450.209(B)(1) or (2). Such a request must be made in writing and received by the MassHealth agency within 33 calendar days of the date appearing on the denial notice, and must include the complete medical record or records. If the hospital requests reconsideration pursuant to 130 CMR 450.209(B)(3), the MassHealth agency will review the medical record or records and notify the hospital of the determination. If the hospital does not timely request reconsideration, the denial issued pursuant to 130 CMR 450.209(B)(1) or (2) constitutes the MassHealth agency's final action, and the hospital will have no right to an adjudicatory hearing pursuant to 130 CMR 450.209(C)(3), because of its failure to exhaust its administrative remedies. (C) Determination of Noncompliance. (1) MassHealth Agency’s Determination. If, based on its review of the information submitted in accordance with 130 CMR 450.209(B), the MassHealth agency determines that an acute hospital inpatient admission was not medically necessary, the MassHealth agency will deny payment for the admission. The hospital may rebill for medically necessary services as an outpatient claim pursuant to 130 CMR 415.414: Utilization Review. If, based on its review, the MassHealth agency determines that the admission was medically necessary but the hospital has failed to comply with the MassHealth agency’s billing procedures and requirements, the MassHealth agency will deny the claim. In such a case, the hospital may rebill the claim pursuant to the proper billing requirements. (2) Requesting Reconsideration. (a) The acute inpatient hospital must request reconsideration of any denial issued in accordance with 130 CMR 450.209(C)(1) in order to be entitled to file a claim for an adjudicatory hearing pursuant to 130 CMR 450.241. Such reconsideration request must be made in writing and received by the MassHealth agency within 33 calendar days of the date appearing on the denial notice, and must include the following: 1. a written statement from a physician explaining why the MassHealth agency's denial was in error. Such explanation must specifically address all clinical issues cited in the MassHealth agency's denial and must not consist solely of the resubmission of previously submitted documents; 2. Administrative Regulations 2. a certification from the acute inpatient hospital's Utilization Review Department (URD) that it has reviewed the medical record or records and believes that both the treatment delivered and the inpatient admission were in compliance with all MassHealth agency regulations about the medical or administrative necessity of the admission, treatment, and continued stay of that patient; and 3. if the MassHealth agency's denial indicates that any service should have been delivered as an outpatient service, the physician statement and URD certification must explain why this would have been contrary to accepted standards of medical practice. (b) If the hospital does not submit a request for reconsideration, the denial issued pursuant to 130 CMR 450.209(C)(1) constitutes the MassHealth agency's final action. If the hospital requests reconsideration but fails to timely comply with the requirements of 130 CMR 450.209(C)(2)(a), the reconsideration request will be summarily denied. In either case, the MassHealth agency's denial constitutes the MassHealth agency's final action, and the hospital has no right to an adjudicatory hearing pursuant to 130 CMR 450.209(C)(3) or judicial review because of its failure to exhaust its administrative remedies. (3) MassHealth Agency’s Final Determination. The MassHealth agency will review a request for reconsideration and accompanying material submitted in compliance with the requirements of 130 CMR 450.209(C)(2) and will issue a final determination based on such review. The determination will be in writing, state the reasons for the determination, and inform the acute inpatient hospital of its right to file a claim for an adjudicatory hearing in accordance with 130 CMR 450.241. The claim will be decided by the Office of Medicaid’s Board of Hearings in accordance with 130 CMR 450.241 through 450.248. (D) Resubmission of Claim after Denial or Pending Review. If the acute inpatient hospital resubmits an inpatient claim for payment that, pursuant to 130 CMR 450.209, has either been denied or is pending review, and if that resubmitted claim is paid by the MassHealth agency, the MassHealth agency will void the payment of the claim when it becomes aware of the resubmission. The hospital may file a claim for an adjudicatory hearing pursuant to 130 CMR 450.241 and 450.243 through 450.248 to contest the voiding of the payment.