Section 12. Review Of Retroactive Prior Approval Review Denials

Providers who disagree with abstract review decisions or denials of retroactive prior approval review can request a re-review and reconsideration. See Section MAD-953, Reconsideration of Utilization Review Decisions for specific information on the review process. [11/1/1996; 8.350.3.12 NMAC - Rn, 8 NMAC 4.MAD.954.3, 3/1/2012] 8.350.3.13 PAYMENT FOLLOWING APPROVAL OF RETROACTIVE PRIOR APPROVAL REVIEW ABSTRACTS: Medicaid reimburses facilities in the following manner after approval of a retroactive prior approval review: A. for late initial abstracts caused by delayed physician signature, reimbursement is effective back to the date of admission; B. for late initial abstracts caused by delayed medicaid eligibility decisions, reimbursement is effective back to the date the recipient became medicaid-eligible; C. for late continued-stay abstracts caused by delays in obtaining physician signature or retroactive medicaid eligibility, reimbursement is effective from the beginning of the certification period for continued stay; D. for the first ten (10) late abstracts per facility per calendar when delay is attributed to circumstances within the facility’s control, reimbursement is effective back to the date of admission or the beginning of the certification period for continued stay applicable to the situation; and E. for late abstracts beyond the ten (10) allowed by medicaid attributed to circumstances within the facility’s control, the earliest possible effective date is the date the late abstract was received by the UR contractor.