R414-32-1.

1. General Requirement

A hospital providing care for any Utah Medicaid patient must provide sufficient documentary evidence that ancillary services for which Medicaid is billed were actually rendered in the diagnosis and/or treatment of that patient and that such services were properly authorized by a licensed physician. If such evidence is not provided in accordance with the provisions of this administrative rule, then reimbursement for such unsupported charges will not be allowed by Medicaid.

2. Documentation That Services Were Rendered

Sufficient documentary evidence that an ancillary service was rendered consists of medical reports, x-rays and laboratory analyses normally provided by the department which renders the service. Department logs may be accepted as documentation that ancillary services were rendered if each entry is signed and dated by an authorized individual rendering the services.

3. Documentation That Services Were Properly Authorized

Sufficient documentary evidence of a physician authorization consists of a written order signed and dated by a licensed physician within the time limits specified in the bylaws of the hospital or within thirty (30) days after the date of discharge, whichever is sooner.

A written departmental protocol is acceptable as authorization if the protocol is specific with respect both to the medical service to be rendered and to the conditions and circumstances under which the service may be given without the direct authorization of a licensed physician. All such protocols must have the formal written approval of the appropriate medical staff committees of the hospital and be signed by the physician in charge of the care unit.

4. Notification of Discrepancies

If, upon examination of a hospital patient's medical record 30 days or more after the patient was discharged, sufficient documentary evidence is not found to support charges for ancillary services, the Department of Health or its agent will notify the hospital in writing of such discrepancy. If within thirty (30) days of the date the hospital is notified of such discrepancy, the hospital compiles in the medical record sufficient documentary evidence in support of the charge that was noted as a discrepancy, then such evidence will be considered sufficient. If the hospital does not place such evidence in the medical record within thirty (30) days after being notified of the discrepancy then reimbursement will not be allowed for the unsupported item. Subsequent presentation of any documentation will not be accepted by the Department of Health.