Section 148.240 Utilization Review and Furnishing of Inpatient Hospital Services Directly or Under Arrangements

Section 148

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 148 HOSPITAL SERVICES

SECTION 148.240 UTILIZATION REVIEW AND FURNISHING OF INPATIENT HOSPITAL SERVICES DIRECTLY OR UNDER ARRANGEMENTS

Section 148.240  Utilization

Review and Furnishing of Inpatient Hospital Services Directly or Under

Arrangements

Effective for dates of discharge

on or after July 1, 2014:

a)         Utilization

Review

The

Department, or its designated peer review organization, shall conduct utilization

review in compliance with Section 1152 of the Social Security (42 U.S.C.

1320c-1) and 42 (Chapter IV, Subchapter F (October 1, 2013).  A peer review

shall be conducted by a Physician Peer Reviewer who is licensed to practice

medicine in all its branches, engaged in the active practice of medicine, board

certified or board eligible in the physician's specialty and has admitting

privileges in one or more Illinois hospitals.  Payment will only be made for

those admissions and days approved by the Department or its designated peer

review organization.  Utilization review may consist of, but not be limited to,

preadmission, concurrent, pre-payment, and post-payment reviews to determine,

pursuant to 42 CFR 476, Subpart C (October 1, 2013), the following:

1)         Whether the services are or were reasonable and medically

necessary for the diagnosis and treatment of illness or injury;

2)         The

medical necessity, reasonableness and appropriateness of hospital admissions

and discharges, including, but not limited to, the coordination of care

requirements defined in Section 148.40(a)(9) for the Children's Mental Health

Screening, Assessment and Support Services (SASS) Program;

3)         Through DRG validation, the validity of diagnostic and procedural

information supplied by the hospital;

4)         The completeness, adequacy and quality of hospital care

provided;

5)         Whether the quality of the services meets professionally

recognized standards

in Section 148.40(a)(9) for the Children's Mental Health

Screening, Assessment and Support Services (SASS) Program;

3)         Through DRG validation, the validity of diagnostic and procedural

information supplied by the hospital;

4)         The completeness, adequacy and quality of hospital care

provided;

5)         Whether the quality of the services meets professionally

recognized standards of health care; or

6)         Whether those services furnished or proposed to be furnished

on an inpatient basis could, consistent with the provisions of appropriate

medical care, be effectively furnished more economically on an outpatient basis

or in an inpatient health care facility of a different type.

b)         Notice

of Utilization Review

The Department

shall provide hospitals with notice 30 days before a service is subject to

utilization review, as described in subsections (c), (d), (e) and (f) of this

Section, that the service is subject to such review.  In determining whether a

particular service is subject to utilization review, the Department may

consider factors that include:

1)         Assessment of appropriate level of care;

2)         The

service could be furnished more economically on an outpatient basis;

3)         The inpatient hospital stays for the service deviate from the

norm for inpatient stays using accepted length of stay criteria;

4)         The cost of care for the service;

5)         Denial rates; and

6)         Trends or patterns that indicate potential for abuse.

c)         Preadmission

Review

Preadmission

review may be conducted prior to admission to a hospital to determine if the

services are appropriate for an inpatient setting.  The Department shall

provide hospitals with notice of the criteria used to determine medical

necessity in preadmission reviews 30 days before a service is subject to

preadmission review.

d)         Concurrent

Review

Concurrent

review consists of a certification of admission and, if applicable, a continued

stay review

al to determine if the

services are appropriate for an inpatient setting.  The Department shall

provide hospitals with notice of the criteria used to determine medical

necessity in preadmission reviews 30 days before a service is subject to

preadmission review.

d)         Concurrent

Review

Concurrent

review consists of a certification of admission and, if applicable, a continued

stay review.

1)         The certification of admission is performed to determine the

medical necessity of the admission and to assign an initial length of stay

based on the criteria for the admission.

2)         The continued stay review is conducted to determine the

medical necessity and appropriateness of continuing the inpatient

hospitalization. More than one continued stay review can be performed in an

inpatient stay.

e)         Pre-payment

Review

The Department

may require hospitals to submit claims to the Department for pre-payment review

and approval prior to rendering payment for services provided.

f)         Post-payment

Review

Post-payment

review shall be conducted on a random sample of hospital stays following

reimbursement to the hospital for the care provided.  The Department may also

conduct post-payment review on specific types of care.

g)         Hospital

Utilization Control

Hospitals and

distinct part units that participate in Medicare (Title XVIII) must use the

same utilization review standards and procedures and review committee for

Medicaid as they use for Medicare.  Hospitals and distinct part units that do

not participate in Medicare must meet the utilization review plan requirements

in 42 CFR 456 (October 1, 2013). Utilization control requirements for inpatient

psychiatric hospital care in a psychiatric hospital, as defined in 89 Ill. Adm.

Code 148.25(d)(1) shall be in accordance with the federal regulations

ttee for

Medicaid as they use for Medicare.  Hospitals and distinct part units that do

not participate in Medicare must meet the utilization review plan requirements

in 42 CFR 456 (October 1, 2013). Utilization control requirements for inpatient

psychiatric hospital care in a psychiatric hospital, as defined in 89 Ill. Adm.

Code 148.25(d)(1) shall be in accordance with the federal regulations.

h)         Denial

of Payment as a Result of Utilization Review

1)         If the Department determines, as a result of utilization

review, that a hospital has misrepresented admissions, length of stay,

discharges, or billing information, or has taken an action that results in the

unnecessary admission or inappropriate discharge of a program participant,

unnecessary multiple admissions of a program participant, unnecessary transfer

of a program participant, or other inappropriate medical or other practices

with respect to program participants or billing for services furnished to

program participants, the Department may, as appropriate:

A)        Deny payment (in whole or in part) with respect to inpatient

hospital services provided with respect to such an unnecessary admission,

inappropriate length of stay or discharge, subsequent readmission, transfer of

an individual or failure to comply with the coordination of care requirements of

Section 148.40.

B)        Require the hospital to take action necessary to prevent or

correct the inappropriate practice.

2)         When payment with respect to the discharge of an individual

patient is denied by the Department or its designated peer review organization,

under subsection (h)(1)(A) as a result of prepayment review, a reconsideration

will be provided within 30 days upon the request of a hospital or physician if

such request is the result of a medical necessity or appropriateness of care

denial determination and is received within 60 days after receipt of the notice

of denial.  The date of the notice of denial is counted as day one

organization,

under subsection (h)(1)(A) as a result of prepayment review, a reconsideration

will be provided within 30 days upon the request of a hospital or physician if

such request is the result of a medical necessity or appropriateness of care

denial determination and is received within 60 days after receipt of the notice

of denial.  The date of the notice of denial is counted as day one.

3)         When payment with respect to the discharge of an individual

patient is denied by the Department or its designated peer review organization

under subsection (h)(1)(A) as a result of a preadmission or concurrent review,

the hospital or physician may request an expedited reconsideration.  The

request for expedited reconsideration must include all the information,

including the medical record, needed for the Department or its designated peer

review organization to make its determination.  A determination on an expedited

reconsideration request shall be completed within one business day after the

Department's or its designated peer review organization's receipt of the

request.  Failure of the hospital or physician to submit all needed information

shall toll the time in which the reconsideration shall be completed.  The

results of the expedited reconsideration shall be communicated to the hospital

by telephone within one business day and in writing within three business days

after the determination.

4)         A determination under subsection (h)(1), if it is related to a

pattern of inappropriate admissions, length of stay and billing practices that

has the effect of circumventing the prospective payment system, may result in:

A)        Withholding payment (in full or in part) to the hospital until

the hospital provides adequate assurances of compliance; or

B)        Termination

of the hospital's Provider Agreement.

i)          Furnishing

of Inpatient Hospital Services Directly or Under Other Arrangements

1)         The applicable payments made under this Part and 89 Ill. Adm

rospective payment system, may result in:

A)        Withholding payment (in full or in part) to the hospital until

the hospital provides adequate assurances of compliance; or

B)        Termination

of the hospital's Provider Agreement.

i)          Furnishing

of Inpatient Hospital Services Directly or Under Other Arrangements

1)         The applicable payments made under this Part and 89 Ill. Adm.

Code 149 are payment in full for all inpatient hospital services other than for

the services of nonhospital-based physicians to individual program participants

and the services of certain hospital-based physicians as described in

subsections (i)(1)(B)(i) through (i)(1)(B)(v).

A)        Hospital-based physicians who may not bill separately on a

fee-for-service basis:

i)          A physician whose salary is included in the hospital's cost

report for direct patient care.

ii)         A teaching physician who provides direct patient care, if the

salary paid to the teaching physician by the hospital or other institution

includes a component for treatment services.

B)        Hospital-based physicians who may bill separately on a

fee-for-service basis:

i)          A physician whose salary is not included in the hospital's

cost report for direct patient care.

ii)         A teaching physician who provides direct patient care, if the

salary paid to the teaching physician by the hospital or other institution does

not include a component for treatment services.

iii)        A resident, when, by the terms of his or her contract with

the hospital, he or she is permitted to and does bill private patients and

collect and retain the payments received for those services.

iv)        A hospital-based specialist who is salaried, with the cost of

his or her services included in the hospital reimbursement costs, when, by the

terms of his or her contract with the hospital, he or she may charge for

professional services and does, in fact, bill private patients and collect and

retain the payments received

d

collect and retain the payments received for those services.

iv)        A hospital-based specialist who is salaried, with the cost of

his or her services included in the hospital reimbursement costs, when, by the

terms of his or her contract with the hospital, he or she may charge for

professional services and does, in fact, bill private patients and collect and

retain the payments received.

v)         A physician holding a nonteaching administrative or staff

position in a hospital or medical school, to the extent that he or she

maintains a private practice and bills private patients and collects and

retains payments made.

2)         Charges are to be submitted on a fee-for-service basis only

when the physician seeking reimbursement has been personally involved in the

services being provided.  In the case of surgery, it means presence in the

operating room, performing or supervising the major phases of the operation,

with full and immediate responsibility for all actions performed as a part of

the surgical treatment.

j)          "Designated peer review organization" means an

organization designated by the Department that is experienced in utilization

review and quality assurance, which meets the guidelines in 42 U.S.C. 1320c-1

and 42 CFR 475 (2013).