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Utah Administrative Code (Current through November 1, 2019) |
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R414. Health, Health Care Financing, Coverage and Reimbursement Policy |
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R414-515. Long Term Acute Care |
| R414-515-1. Introduction and Authority |
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This rule defines the scope of inpatient long-term acute care hospital (LTAC) services that are available to Medicaid members for the treatment of disorders other than mental disease. This rule is authorized by Subsection 1886(d)(1)(B)(iv)(I) of the Social Security Act and Sections 26-1-5, 26-18-2.1, 26-18-2.3, and 26-18-3. |
| R414-515-2. Definitions |
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(1) "Admission" means the acceptance of a Medicaid member for LTAC care and treatment when the member meets established evidence-based criteria for severity of illness and intensity of service and the required service cannot be provided in a lesser level of care setting. (2) "Comprehensive documentation" means applicable relevant information including a history and physical, operative reports, daily physician progress notes, vital signs, laboratory test results, medications administration records, respiratory therapy notes, wound care notes, nutrition notes, physical therapy notes, occupational therapy notes, speech therapy notes, and any other pertinent information the Division needs to make a decision regarding the LTAC request. (3) "Continued stay review" means a periodic, supplemental, or interim review of clinical information for an LTAC member. (4) "Inpatient" means an individual whose severity of illness and intensity of service meet the evidence-based criteria for an LTAC stay. (5) "Intensity of Service" means measure of the number, technical complexity, or attendant risk of services provided. (6) "Long-term acute care hospital" or "Long-term care hospital" (LTAC) means an inpatient transitional care hospital designed to treat members with multiple, serious medical conditions requiring intense, acute care as determined by a physician. (7) "Retroactive review" means a review of clinical information for a patient who had previously been admitted to an LTAC, but never received a prior authorization for the initial or continued stay due to retroactive eligibility approval. (8) "Severity of Illness" means the extent of organ system derangement or physiologic decompensation for a patient. |
| R414-515-3. Client Eligibility Requirements |
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A patient must be eligible for Medicaid services. |
| R414-515-4. Program Access Requirements |
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(1) A member must meet the severity of illness and intensity of service for LTAC level of care as determined through an evidence-based criteria review process. (a) The Department shall deny an LTAC request for reimbursement if the member does not meet the evidence-based criteria. (b) The evidence-based criteria subsets must be utilized correctly (e.g., the primary diagnosis may not additionally be used as a secondary diagnosis). (2) LTAC preadmissions, continued stays, and retroactive stays that do not meet the evidence-based criteria subsets may be forwarded for secondary medical review if: (a) the LTAC requests the secondary medical review; or (b) documentation shows that LTAC is the most appropriate level of care for the member. |
| R414-515-5. Service Coverage |
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(1) An LTAC provider must submit to the Department a request for coverage that includes current and comprehensive documentation, or the Department will return the request as incomplete. (2) The Department shall consider LTAC coverage upon the date it receives the request and current, comprehensive documentation. (3) The Department shall review the documentation to determine preadmission, continued stay, or retroactive stay within three business days of the request. (4) Prior authorization is not transferable from one LTAC to another. (5) Prior authorization is required for preadmission, continued stay, and retroactive reviews. (6) If a member transfers from an LTAC to an acute care hospital for any reason, and is away from the LTAC for greater than 24 hours, the LTAC shall submit a new preadmission review before transferring the member back to the LTAC. (7) Each approved prior authorization is for a seven-day period. |
| R414-515-6. Preadmission Review |
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An LTAC provider shall submit prior authorization requests to the Department at least 24 hours before the expected admission. |
| R414-515-7. Continued Stay Review |
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An LTAC provider shall submit prior authorization requests to the Department two days before the end of the approved period. The continued stay prior authorization request must include all pertinent medical record comprehensive documentation supporting the evidence-based LTAC continued stay review. |
| R414-515-8. Reimbursement Methodology |
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Reimbursement for LTAC is in accordance with the Utah Medicaid State Plan. |