<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".08" citation="COMAR 10.09.93.08" title_num="10" subtitle_num="09" chapter_num="93" heading="Utilization Review.">
  <paragraph num="A.">
    <text>Admission and Prior Approval.</text>
    <paragraph num="(1)">
      <text>For participants and individuals who have applied for Medical Assistance, the provider shall request a determination from the Department or its designee at the time of admission, or at the time of application for Medical Assistance, that the individual meets the medical eligibility criteria set forth in Regulation .07A of this chapter.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>For a participant to be preauthorized for services in a brain injury community integration program, a provider that meets the requirements of Regulation .04 of this chapter shall request a determination from the Department or its designee that the participant meets the criteria set forth in Regulation .07B of this chapter.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>If the provider obtains the determination set forth in §A(1) or (2) of this regulation after admission, the eligibility determination shall be effective on the date that the determination was requested.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Concurrent Review.</text>
    <paragraph num="(1)">
      <text>On a monthly basis, the provider shall notify the Department or its designee of all persons who have:</text>
      <paragraph num="(a)">
        <text>Received an initial determination of medical eligibility for chronic hospital services;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Been determined to continue to meet medical eligibility criteria for chronic hospital services;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Been discharged; or</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Been determined to no longer be medically eligible.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Concurrent review shall be conducted every 14 days as long as the participant remains hospitalized to ensure the medical necessity of the participant’s inpatient stay.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The Department or its designee may conduct on-site reviews.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Administrative Days.</text>
    <paragraph num="(1)">
      <text>To be paid for administrative days, the provider shall document, in a form designated by the Department, information which satisfies the conditions listed below:</text>
      <paragraph num="(a)">
        <text>The participant who was initially eligible has been determined to no longer require chronic hospital services, and the provider has:</text>
        <paragraph num="(i)">
          <text>Received a determination from the Department or its designee that the participant requires the level of service provided by a nursing facility but an appropriate facility is not available;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Established a plan for discharge during the period of administrative days, is actively pursuing placement at an appropriate level of care for the participant, and has documented this activity in the participant’s record; and</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Submitted documentation to the Department or its designee that placement activity was conducted no fewer than 3 days per week during the period for which payment is requested for administrative days; or</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>The participant is no longer medically eligible to receive chronic hospital services but cannot be moved, and the following conditions are met:</text>
        <paragraph num="(i)">
          <text>The medical reason the participant cannot be moved is documented by the attending physician in the participant’s medical record;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>The attending physician reevaluates the medical cause of the participant’s inability to be moved at least once every 7 days; and</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>The provider documents the active treatments used to resolve the medical cause of the participant’s inability to be moved;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>To receive reimbursement for administrative days, the provider shall document that it has met the conditions of §C(1) of this regulation, at least every 14 days.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Documentation shall be submitted to the Department or its designee no later than 3 business days following the end of the 14-day period.</text>
    </paragraph>
  </paragraph>
</regulation>