R414-515-4. Program Access Requirements

  (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.