Minnesota Administrative Rules

9505.0530 INCORPORATION BY REFERENCE OF CRITERIA TO DETERMINE MEDICAL NECESSITY.

Subpart 1.

Determinations using medical necessity criteria.

The medical review agent shall follow the medical necessity criteria specified in subparts 2 and 3 in determining the following:

A.

whether a recipient's admission is medically necessary;

B.

whether the inpatient hospital services provided to the recipient were medically necessary;

C.

whether the recipient's continued stay was or will be medically necessary; and

D.

whether all medically necessary inpatient hospital services were provided to the recipient.

Subp. 2.

Criteria for inpatient hospital admission; general.

The most recent edition of the Appropriateness Evaluation Protocol of the National Institutes of Health is incorporated by reference. The book was published in 1984 by the Health Data Institute, 20 Maguire Road, Lexington, Massachusetts, 02173, and it is available through the Minitex interlibrary loan system. The book is not subject to change.

Subp. 3.

Criteria for inpatient psychiatric treatment.

The Criteria for Inpatient Psychiatric Treatment, 1981 edition, revised 1991, published by Blue Cross and Blue Shield of Minnesota are incorporated by reference. The criteria are available at Blue Cross and Blue Shield of Minnesota, P.O. Box 64560, Saint Paul, Minnesota 55164, and at the State Law Library, Minnesota Judicial Center, 25 Rev. Dr. Martin Luther King Jr. Blvd., Saint Paul, Minnesota 55155. The criteria are not subject to frequent change.

Statutory Authority:

MS s 256.9353; 256B.04; 256B.503; 256D.03

History:

9 SR 2296; 11 SR 1687; 13 SR 1688; 23 SR 298

Published Electronically:

August 12, 2008