Minnesota Administrative Rules

9505.0520 INPATIENT ADMISSION CERTIFICATION.

Subpart 1.

Requirement for admission certification.

Except as provided in subpart 2, a hospital or admitting physician furnishing inpatient hospital services to a recipient must obtain admission certification in order for the admitting physician, the hospital, or other provider of an inpatient hospital service to receive medical assistance payment for the inpatient hospital services to the recipient.

A.

Admission certification must be obtained when a recipient is admitted, readmitted, or transferred to a hospital unless the admission is combined under the readmission criteria of part 9505.0540.

B.

An admission certification number is valid only for the hospital admission for which it is issued, except in circumstances specified in part 9505.0540.

C.

Admission certification for the admission of a MinnesotaCare recipient must be requested within 30 days of the date of admission or be subject to penalties under Minnesota Statutes, section 256L.03, subdivision 3, paragraph (b).

Subp. 2.

Exclusions from admission certification.

Admissions for inpatient hospital services under items A to C shall be excluded from the requirement in subpart 1. The admissions are subject to retrospective review as stated in subpart 10.

A.

The admission of a pregnant woman that results in the delivery of a newborn or a stillbirth, and the admission of a newborn resulting from birth.

B.

The admission is for Medicare Part A covered inpatient hospital services which are provided to a recipient who is also eligible for medical assistance and for which medical assistance payment is requested for the coinsurance and deductible payments only.

C.

An admission to a hospital that is not located in Minnesota or the local trade area for which a prior authorization has been obtained according to parts 9505.5000 to 9505.5030.

Subp. 3.

Admitting physician and hospital responsibilities.

The admitting physician or hospital that seeks medical assistance payment for inpatient hospital services provided to a recipient must follow the procedures in items A to C.

A.

Request admission certification by contacting the medical review agent either by telephone or in writing and providing the information in subitems (1) to (8):

(1)

hospital's medical assistance provider number and name;

(2)

recipient's name, recipient ID number, sex, and date of birth;

(3)

admitting physician's name and medical assistance provider number;

(4)

primary procedure, or principal procedure, when applicable, according to the most recent edition of Current Procedural Terminology published by the American Medical Association or the International Classification of Diseases -- Clinical Modification, published by the Practice Management Information Corporation, 4727 Wilshire Boulevard, Los Angeles, CA 90010 which are incorporated by reference. These books are available through the Minitex interlibrary loan system and are subject to change;

(5)

date of admission, or expected date of admission;

(6)

whether the admission is a readmission or a transfer;

(7)

admitting diagnosis, or principal diagnosis, when applicable, according to the most recent edition of the International Classification of Diseases -- Clinical Modification; and

(8)

information from the plan of care and the reason for admission as necessary for the medical review agent to determine if admission is or was medically necessary.

B.

Inform all providers involved in the recipient's inpatient hospital services of the certification number.

C.

For purposes of billing, enter the certification number on invoices submitted to the department for payment.

Subp. 4.

[Repealed, 23 SR 298]

Subp. 5.

[Repealed, 23 SR 298]

Subp. 6.

[Repealed, 23 SR 298]

Subp. 7.

Ineligibility to serve as physician or physician adviser.

A physician shall not be eligible to determine the medical necessity of an admission under parts 9505.0501 to 9505.0545 if:

A.

the physician is the admitting physician for the admission for which certification is being requested;

B.

during the previous 12 months, the physician issued treatment orders or participated in the formulation or execution of the treatment plan for the recipient for whom admission certification is requested;

C.

the physician and the physician's family, which means the physician's spouse, child, grandchild, parent, or grandparent, has an ownership interest of five percent or more in the hospital for which admission certification is being requested; or

D.

the physician can obtain a financial benefit from the admission of the recipient.

Subp. 8.

Procedure for admission certification.

The procedures for admission certification are listed in items A to I.

A.

Upon receipt of the information requested in subpart 3, item A, the medical review agent shall review the information and determine whether the admission is medically necessary.

B.

If the medical review agent determines that the admission is medically necessary, the medical review agent shall issue a certification number.

C.

If the medical review agent is unable to determine that the admission is medically necessary, the medical review agent shall contact a physician.

D.

If the physician determines that the admission is medically necessary, the medical review agent shall issue a certification number.

E.

If the physician determines that the admission is not medically necessary or is unable to determine that the admission is medically necessary, the medical review agent shall notify the provider by telephone, and the provider may request within 24 hours of the medical review agent's notification, exclusive of weekends and holidays, a second physician's opinion.

F.

If the provider requests a second physician's opinion, the medical review agent shall contact a second physician. If the second physician determines that the admission is medically necessary, the medical review agent shall issue a certification number.

G.

If the second physician determines that the admission is not medically necessary, or is unable to determine that the admission is medically necessary, or if the provider does not request a second physician's opinion when the first physician determines that the admission is not medically necessary or is unable to determine that the admission is medically necessary, then the medical review agent shall deny the admission certification and shall not issue a certification number.

H.

The medical review agent shall make the determination about medical necessity and inform the provider by telephone within 24 hours of the receipt of the information requested in subpart 3, item A, exclusive of weekends and holidays, unless the provider requests a second physician's opinion. If the provider requests a second physician's opinion, the medical review agent shall make the determination of medical necessity and notify the provider by telephone within 24 hours of the request, exclusive of weekends and holidays. The medical review agent shall send a written notice of the determination to the hospital and admitting physician within five working days of the determination. In the case of a denial, the written notices to the hospital and the admitting physician required under this item must be sent by certified mail. The denial notices to the admitting physician and hospital must state the reasons for the denial and inform the admitting physician or hospital that a reconsideration may be requested under subpart 9. In the case of a denial when the recipient has not received the inpatient hospital services, the medical review agent shall send a written notice of the denial to the recipient within five working days of the determination. The denial notice to the recipient must state the recipient's right of appeal under part 9505.0545 and Minnesota Statutes, section 256.045.

I.

When there is a need to further substantiate the medical necessity of the admission, the department or medical review agent may request that the provider submit, at the provider's expense, a copy of the recipient's medical record or part of the medical record needed to make the determination. If the provider fails to submit a requested record within 30 days of the date of the request, the department or the medical review agent shall make a determination based on the information available.

Subp. 9.

Reconsideration requested.

The admitting physician or the hospital may request reconsideration of a decision to deny or withdraw an admission certification if:

A.

the medical review agent denies an admission certification number because the admission is not medically necessary;

B.

the medical review agent withdraws an admission certification number for all or part of a recipient's stay because all or part of the stay was not medically necessary based on a concurrent or retrospective review; or

C.

the medical review agent denies or withdraws an admission certification number or considers an admission and readmission to be a transfer under the readmission criteria in part 9505.0540 because the admission and readmission meet the criteria specified in part 9505.0540.

The admitting physician or the hospital shall submit a written request for reconsideration to the medical review agent within 30 days of the date of receipt of the certified letter from the medical review agent denying or withdrawing the admission certification number. The request must include the recipient's name and the recipient's ID number; the disputed admission; the reason for the dispute; the medical record or the part of the medical record needed to make a determination of the medical necessity of the admission or appropriateness of a readmission and any other information related to the admission and determination; and the name, address, and telephone number of the person to contact about the reconsideration.

Subp. 9a.

[Repealed, 23 SR 298]

Subp. 9b.

[Repealed, L 2023 c 70 art 17 s 63]

Subp. 9c.

Completion of reconsideration.

The medical review agent shall complete the reconsideration requested under subpart 9 within 60 days of receipt of the information required under subpart 9. The medical review agent shall notify the provider who requested the reconsideration, by telephone, of the decision within 24 hours of receipt of the physician adviser's determination, exclusive of weekends and holidays. A written notice of the decision must be sent by certified mail to the hospital and the admitting physician by the medical review agent within ten working days of the receipt of the physician adviser's determination. In the event a denial is upheld, the notice must inform the admitting physician and hospital of the right to request an appeal of the reconsideration decision within 30 days of receiving the notice according to Minnesota Statutes, section 256.9685, subdivisions 1b to 1d.

Subp. 10.

Medical record review and determination after admission.

The department or the medical review agent may conduct a concurrent, continued stay or retrospective review of a recipient's medical record to establish the recipient's diagnosis and procedure codes and to determine whether the recipient's admission and all the inpatient hospital services provided to the recipient were medically necessary, whether a continued stay was medically necessary or will be medically necessary, and whether all medically necessary inpatient hospital services were provided to the recipient. In making a determination under this subpart, the medical review agent must follow the procedure in items A to G.

A.

The medical review agent shall review the medical record to establish the diagnosis and procedure codes for diagnostic category validation. Additionally, the medical review agent may review the bills, invoices, and all supporting documentation pertaining to a request for medical assistance payment.

B.

The medical review agent may request additional information from the admitting physician or the hospital as necessary to clarify the medical record if the medical review agent is unable to determine that the recipient's admission was medically necessary, that all inpatient hospital services provided to the recipient were medically necessary, that the recipient's continued stay was medically necessary or will be medically necessary, or that all medically necessary inpatient hospital services were provided. The additional information must be submitted at the expense of the admitting physician or hospital.

C.

If, after additional information is submitted, the medical review agent is unable to determine that the recipient's admission was medically necessary, that the recipient's continued stay was medically necessary or will be medically necessary, or that all medically necessary inpatient hospital services were provided, the medical review agent must consult a physician.

D.

If a physician determines that the recipient's admission was not medically necessary, or that all medically necessary inpatient hospital services were not provided, the medical review agent shall withdraw the previously issued certification number and shall notify the admitting physician and hospital of the determination by certified letter mailed within five working days. The notice shall state the right of the admitting physician and hospital to request a reconsideration under subpart 9.

E.

If a physician determines that the recipient's continued stay was not medically necessary or will not be medically necessary, the portion of the stay determined not to be medically necessary will be denied. If the recipient is still an inpatient, the medical review agent shall notify the admitting physician and hospital of the determination by telephone within 24 hours of receipt of the determination, exclusive of weekends and holidays, and by certified letter mailed within five working days of receipt of the determination. If the recipient has been discharged, the medical review agent shall notify the admitting physician and hospital of the determination by certified letter mailed within five working days of receipt of the determination. The notice must state the right of the admitting physician and hospital to request a reconsideration under subpart 9.

F.

If recertification of a recipient's need for inpatient hospital services was required but was not documented in the medical record, the medical review agent shall deny that portion of the admission that was not recertified.

G.

If the medical review agent is unable to determine from the documentation in the recipient's medical records the reasons for the recipient's discharge and readmission according to criteria in part 9505.0540, the medical review agent shall submit the medical records of the recipient's admission and readmission to a physician. The physician shall review the records and determine the nature of the discharge and readmission according to the criteria in part 9505.0540, and if the determination of the medical review agent is different from that of the admitting physician or hospital, then the medical review agent shall notify the admitting physician and hospital by certified letter mailed within five working days. The notice must state the right of the admitting physician and hospital to request a reconsideration under subpart 9.

Subp. 11.

Payment adjustments.

The department may make payment adjustments according to the circumstances in items A to E.

A.

For hospitals receiving payments under parts 9500.1090 to 9500.1140, and admitting physicians and other providers of inpatient hospital services receiving payments through medical assistance, if the admission was not medically necessary or the medical record does not adequately document that the admission was medically necessary, the entire payment shall be denied or recovered. If the hospital, admitting physician, and other providers of inpatient hospital services failed to provide inpatient hospital services that were medically necessary, the department may take action under parts 9505.2160 to 9505.2245.

B.

For hospitals receiving payments under parts 9500.1090 to 9500.1140, and admitting physicians and other providers of inpatient hospital services receiving payments through medical assistance, if the admission was medically necessary but some or all of the additional inpatient hospital services were not or will not be medically necessary, or the medical record does not adequately document that the additional inpatient hospital services were or will be medically necessary, payment for the additional services shall be denied or recovered. If the hospital, admitting physician, and other providers of inpatient hospital services failed to provide inpatient hospital services that were medically necessary, the department may take action under parts 9505.2160 to 9505.2245.

C.

If the diagnostic category validation indicates a discrepancy between the diagnostic category assigned to the claim and the diagnostic category established from the medical record, the department shall adjust the payment as applicable to the diagnostic category that is accurate for the recipient's condition according to the medical record.

D.

If, within 30 days, the hospital failed to comply with the department's or the medical review agent's request to submit the medical record or other required information, all or part of the payment shall be denied or recovered as provided in items A to C.

E.

The provider may not seek payment from the recipient for inpatient hospital services provided under parts 9505.0501 to 9505.0545 if the certification number is not issued or is withdrawn.

Subp. 12.

[Repealed, 23 SR 298]

Subp. 13.

[Repealed, 23 SR 298]

Subp. 14.

[Repealed, 23 SR 298]

Subp. 15.

[Repealed, 23 SR 298]

Statutory Authority:

MS s 256.0625; 256.9353; 256.991; 256B.04; 256B.503; 256D.03

History:

9 SR 2296; 11 SR 1687; 13 SR 1688; 20 SR 2405; 23 SR 298

Published Electronically:

November 30, 2023