Minnesota Legislature
Office of the Revisor of Statutes
Minnesota Administrative Rules
9505.0505 DEFINITIONS.
Subpart 1.
Scope.
As used in parts 9505.0501 to 9505.0545, the following terms have the meanings given them.
Subp. 2.
Admission.
"Admission" means the time of birth at a hospital or the act that allows the recipient to officially enter a hospital to receive inpatient hospital services under the supervision of a physician who is a member of the medical staff.
Subp. 3.
Admission certification.
"Admission certification" means the determination of the medical review agent that all or part of a recipient's inpatient hospital services are medically necessary and that medical assistance, general assistance medical care, or MinnesotaCare funds may be used to pay the admitting physician, hospital, and other vendors of inpatient hospital services for providing medically necessary services, subject to parts 9500.1090 to 9500.1140; 9505.0170 to 9505.0475; 9505.1000 to 9505.1040; and 9505.5000 to 9505.5105.
Subp. 4.
Admitting physician.
"Admitting physician" means the physician who orders the recipient's admission to the hospital.
Subp. 5.
Certification number.
"Certification number" means the number issued by the medical review agent that establishes that all or part of a recipient's inpatient hospital services are medically necessary.
Subp. 6.
Commissioner.
"Commissioner" means the commissioner of human services or an authorized representative of the commissioner.
Subp. 7.
Concurrent review.
"Concurrent review" means a review and determination performed while the recipient is in the hospital and focused on the medical necessity of inpatient hospital services. The review consists of admission review, continued stay review, and, when appropriate, procedure review.
Subp. 8.
Continued stay review.
"Continued stay review" means a review and determination, after the admission certification, of the medical necessity of continued inpatient hospital services to the recipient.
Subp. 10.
Diagnostic categories.
"Diagnostic categories" means the diagnostic classifications established under Minnesota Statutes, section 256.969, subdivision 2.
Subp. 11.
Diagnostic category validation.
"Diagnostic category validation" means the process of comparing the medical record to the information submitted on the inpatient hospital billing form to ascertain the accuracy of the information upon which the diagnostic category was assigned.
Subp. 13.
General assistance medical care or GAMC.
"General assistance medical care" or "GAMC" means the program established by Minnesota Statutes, section 256D.03.
Subp. 14.
Hospital.
"Hospital" means a facility defined in Minnesota Statutes, section 144.696, subdivision 3, and licensed under Minnesota Statutes, sections 144.50 to 144.58, or an out-of-state facility licensed to provide acute care under the requirements of the state in which it is located or an Indian health service facility designated by the federal government to provide acute care.
Subp. 15.
Inpatient hospital service.
"Inpatient hospital service" means a service provided by or under the supervision of a physician after admission to a hospital and furnished in the hospital, including outpatient services provided by the same hospital that immediately precede the admission.
Subp. 16.
Medical assistance or MA.
"Medical assistance" or "MA" means the program established under title XIX of the Social Security Act, United States Code, title 42, chapter 7, subchapter XIX, and Minnesota Statutes, chapter 256B. For purposes of parts 9505.0501 to 9505.0545, "medical assistance" includes general assistance medical care and MinnesotaCare unless otherwise specified.
Subp. 17.
Medical record.
"Medical record" means the information required in part 9505.2175, subpart 2.
Subp. 18.
Medical review agent.
"Medical review agent" means the representative of the commissioner who is authorized by the commissioner to administer procedures for admission certifications, medical record reviews and reconsideration, and perform other functions as stipulated in the terms of the agent's contract with the department.
Subp. 19.
Medically necessary.
"Medically necessary" means an inpatient hospital service that is consistent with the recipient's diagnosis or condition, and under the criteria in part 9505.0530 cannot be provided on an outpatient or other basis.
Subp. 20.
Medicare.
"Medicare" means the federal health insurance program for the aged and disabled under title XVIII of the Social Security Act, United States Code, title 42, chapter 7, subchapter XVIII.
Subp. 21.
MinnesotaCare.
"MinnesotaCare" means the program established in Minnesota Statutes, section 256L.02.
Subp. 22.
Physician.
"Physician" means a person licensed to provide services within the scope of the profession as defined in Minnesota Statutes, chapter 147.
Subp. 23.
Physician adviser.
"Physician adviser" means a physician who practices in the specialty area of the recipient's admitting or principal diagnosis or a specialty area related to the admitting or principal diagnosis.
Subp. 24.
Prior authorization.
"Prior authorization" means the prior approval for medical services by the department as required under Minnesota Statutes, sections 256.9353, subdivisions 1 and 3, and 256B.0625, subdivision 25, and applicable rules adopted by the commissioner.
Subp. 25.
Principal diagnosis.
"Principal diagnosis" means the condition established, after study, as the reason for the admission of the recipient to the hospital for inpatient hospital services.
Subp. 26.
Principal procedure.
"Principal procedure" means a procedure performed for definitive treatment of the recipient's principal diagnosis rather than one performed for diagnostic or exploratory purposes or a procedure necessary to take care of a complication. When multiple procedures are performed for definitive treatment, the principal procedure is the procedure most closely related to the principal diagnosis.
Subp. 27.
Provider.
"Provider" means an individual or organization under an agreement with the department to furnish health services to persons eligible for the medical assistance, MinnesotaCare, or general assistance medical care programs.
Subp. 28.
Provider number.
"Provider number" means a number issued by the department to a provider who has signed a provider agreement under part 9505.0195.
Subp. 29.
Readmission.
"Readmission" means an admission that occurs within 15 days of a discharge of the same recipient. The 15-day period does not include the day of discharge or the day of readmission.
Subp. 30.
Recertification.
"Recertification" means the procedure by which a physician, or physician assistant or nurse practitioner acting within the scope of practice as defined by state law and under supervision of a physician, authorizes a recipient's continued need for inpatient hospital services as required by federal regulations. An admission must be recertified for every 60 days of continuous hospitalization of a recipient beginning from the date of the admission and must be documented in the medical record. Recertification does not apply to general assistance medical care or MinnesotaCare recipients.
Subp. 31.
Recipient.
"Recipient" means a person who is eligible for the medical assistance, general assistance medical care, or MinnesotaCare program.
Subp. 32.
Recipient ID number.
"Recipient ID number" means the unique eight digit identification number assigned to a recipient who has been determined eligible for medical assistance, general assistance medical care, or MinnesotaCare.
Subp. 33.
Reconsideration.
"Reconsideration" means a review of a denial or withdrawal of admission certification according to part 9505.0520, subparts 9, 9b, and 9c.
Subp. 34.
Retrospective review.
"Retrospective review" means a review conducted after inpatient hospital services are provided to a recipient. The review is focused on validating the diagnostic category, verifying recertification, where applicable, and determining the medical necessity of the admission, the medical necessity of any inpatient hospital services provided, and whether all medically necessary inpatient hospital services were provided.
History:
23 SR 298
Published Electronically:
January 14, 2010
Official Publication of the State of Minnesota
Revisor of Statutes