Inpatient rehabilitation hospital services review is a prior approval process to determine the medical necessity, appropriateness of setting, and length of stay for Medicaid recipients being admitted to inpatient rehabilitation centers with a primary emphasis on physical therapy, occupational therapy, and/or speech therapy.
The rehabilitation hospital is responsible for calling to request approval of the planned admission prior to the patient's admission. This allows for expeditious review of the planned admission to allow the provider to have an opportunity to fully evaluate the patient's status. The review is partially entered into our system and held until the facility calls with the actual admission date (see procedure for approval below). The facility is responsible for calling in to confirm the date of actual admission within five calendar days of review; if the patient is not admitted within five days of the review, a new review to assess the patient's current status will be required. If the facility does not call back with an admission date within two weeks of the initial call, the review will be closed; an authorization number is not provided to the facility until the recipient has actually been admitted. If a patient has been out of the inpatient rehabilitation setting for a period equal to or greater than five midnights (e.g., out on pass, hospitalized at an acute care hospital), the facility must request a new initial telephone review.
Inpatient rehabilitation services review includes a continued stay review (performed via record abstract) during the recipient's continued stay in the rehabilitation facility. For stays beyond the initial approved period (a maximum of 14 days length of stay), the inpatient rehabilitation hospital is responsible for submitting a record abstract MAD-331 to Medicaid UR by the last date of the initial approved period; the date of receipt is considered in calculating approved days. Supporting documentation for continued stays must be provided, including evaluations by each of the involved therapies, current assessment of the patient, goals and objectives with target dates, the types and intensities of the planned therapies, and a discussion of the rehabilitation progress since the last review. If the continued stay request is received after expiration of the initial review, the authorization is only for the medically appropriate days starting with the receipt date.
When a recipient has reached maximum rehabilitative potential, the review will be considered as a request for days awaiting placement (DAP) while awaiting other placement. Such days may be granted to the inpatient rehabilitation facility provided they are actively seeking placement. The inpatient rehabilitation facility is responsible for calling or writing to request days awaiting placement; however, Medicaid UR can also make the determination that the review has reached days awaiting placement status. At each review for DAP, providers must clearly illustrate that every attempt is being made to place the patient.
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