Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-501

Preadmission Authorization, Retroactive Authorization, and Continued Stay Review

Notice of Proposed Rule

(Amendment)

DAR File No.: 34267
Filed: 11/30/2010 05:10:35 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to remove language that unnecessarily incorporates federal law by reference.

Summary of the rule or change:

This change removes language that unnecessarily incorporates federal law by reference. It also clarifies statutory authority and makes other minor corrections.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

This rule or change incorporates by reference the following material:

• Removes 42 U.S.C. Sec. 1396r, published by Government Printing Office, 01/03/2007
• Removes 42 CFR 483, published by Government Printing Office, 10/01/2009
• Removes 42 U.S.C. Sec. 1396a(a)(3) , published by Government Printing Office, 01/03/2007
• Removes 42 CFR 431.200 through 431.246 , published by Government Printing Office, 10/01/2009
• Removes 42 U.S.C. Sec. 1396a(a)(7) , published by Government Printing Office, 01/03/2007
• Removes 42 CFR 431.300 through 431.307, published by Government Printing Office, 10/01/2009

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only clarifies and removes unnecessary language from the rule text. It neither affects Medicaid services nor does it affect Medicaid eligibility.

local governments:

There is no impact to local governments because they do not fund or provide Medicaid services and do not determine Medicaid eligibility.

small businesses:

There is no impact to small businesses because this change only clarifies and removes unnecessary language from the rule text. It neither affects Medicaid services nor does it affect Medicaid eligibility.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid clients and to Medicaid providers because this change only clarifies and removes unnecessary language from the rule text. It neither affects Medicaid services nor does it affect Medicaid eligibility.

Compliance costs for affected persons:

There are no compliance costs because this change only clarifies and removes unnecessary language from the rule text. It neither affects Medicaid services nor does it affect Medicaid eligibility.

Comments by the department head on the fiscal impact the rule may have on businesses:

No changes with fiscal impact on business are present in the technical changes made by this proposed rule.

David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

01/14/2011

This rule may become effective on:

01/21/2011

Authorized by:

David Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-501. Preadmission Authorization, Retroactive Authorization, and Continued Stay Review.

R414-501-1. Introduction and Authority.

This rule implements the nursing facility and utilization requirements of 42 U .S .C . Sec. 1396r(b)(3), (e)(5), and (f)(6)(B), [and] 42 CFR 456.1 through 456.23, and 456.350 through 456.380, by requiring the evaluation of each resident's need for admission and continued stay in a nursing facility. It also implements the requirements for states and long term care facilities found in 42 CFR 483.[42 USC 1396r, requirements for nursing facilities, and 42 CFR 483, requirements for states and long term care facilities, are adopted and incorporated by reference.]

 

R414-501-9. General Provisions.

(1) The Department is solely responsible for approving or denying a Preadmission, Retroactive or continued stay authorization for payment for nursing facility services provided to a Medicaid resident. The Department is ultimately responsible for determining if a Medicaid resident has a clinical need for nursing facility services. If the Department determines a nursing facility applicant or Medicaid resident does not have a clinical need for nursing facility services, a written notice of agency action, in accordance with 42 CFR 431.200 through 431.246, 42 CFR 456.437 and 456.438 will be sent. If a nursing facility complies with all Preadmission Authorization, Retroactive Authorization and continued stay requirements for a Medicaid resident then the Department will provide coverage consistent with the State Plan.

(2) If a nursing facility fails to comply with all Preadmission Authorization, Retroactive Authorization or continued stay requirements, the Department will deny payment to the nursing facility for services provided to the nursing facility applicant. The nursing facility is liable for all expenses incurred for services provided to the nursing facility applicant on or after the date the nursing facility applicant applied for Medicaid. The nursing facility will not bill the nursing facility applicant or his legal representative for services not reimbursed by the Department due to the nursing facility's failure to follow Preadmission Authorization, Retroactive Authorization or continued stay rules.

(3) If the application is incomplete it will be denied. The Department will comply with notice and hearing requirements as defined in 42 CFR 431.200 through 431.246, and also send written notice to the nursing facility administrator, the attending physician, and, if possible, the next-of-kin or legal representative of the nursing facility applicant. If the Department denies a claim, the nursing facility can resubmit additional documentation not later than 60 calendar days after the date the Department receives the initial Preadmission or Retroactive Authorization request or continued stay transmittal. If the nursing facility fails to submit additional documentation that corrects the claim deficiencies within the 60 calendar day period, then the denial becomes final and the nursing facility waives all rights to Medicaid reimbursement from the time of admission until the Department approves a subsequent request for authorization submitted by the nursing facility.

(4) The Department adopts the standards and procedures for conducting a fair hearing set forth in 42 U .S .C . Sec. 1396a(a)(3) and 42 CFR 431.200 through 431.246,[which are incorporated by reference. Those laws are] and as implemented in [Title 63G, Chapter 4 and in] Rule R410-14.

 

R414-501-10. Safeguarding Information of Nursing Facility Applicants and Residents.

(1) The Department adopts the standards and procedures for safeguarding information of nursing facility applicants and recipients set forth in 42 U .S .C . Sec.1396a(a)(7) and 42 CFR 431.300

through 431.307[, which are incorporated by reference].

(2) Standards for safeguarding a resident's private records are set forth in Section 63G-2-302.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [October 14, 2009]2011

Notice of Continuation: August 20, 2009

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3[; 63G-3-304(1)(a)]