<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".06" citation="COMAR 10.09.95.06" title_num="10" subtitle_num="09" chapter_num="95" heading="Utilization Review Requirements.">
  <paragraph num="A.">
    <text>Elective Inpatient Preauthorization Reviews.</text>
    <paragraph num="(1)">
      <text>The special psychiatric hospital shall only request preauthorization for inpatient stays when such services:</text>
      <paragraph num="(a)">
        <text>Cannot be provided on an outpatient basis; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Can only be provided in a facility that is licensed as a special psychiatric hospital.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The special psychiatric hospital shall obtain preauthorization for elective inpatient admissions from the Department or its designee, before the participant is admitted, by providing the following information including, but not limited to:</text>
      <paragraph num="(a)">
        <text>Participant’s medical history and physical; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Sufficient clinical information or documentation that supports the medical necessity of the inpatient admission.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Concurrent Review Process.</text>
    <paragraph num="(1)">
      <text>The concurrent review process shall be initiated by the hospital.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>If the participant remains hospitalized, additional days shall be certified by the Department or its designee before the termination of the previously certified days.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The special psychiatric hospital shall forward sufficient clinical information or documentation to the Department or its designee that supports the need for continuing care. Information submitted shall include:</text>
      <paragraph num="(a)">
        <text>Current health status;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Treatment received to date;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Proposed treatment plan for continued stay; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Discharge planning.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Retrospective Reviews.</text>
    <paragraph num="(1)">
      <text>The special psychiatric hospital shall request that the Department or its designee perform a retrospective review of an inpatient admission after the participant is discharged, to determine the medical necessity of the admission.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The special psychiatric hospital shall provide the following to the Department or its designee when requesting a retrospective review following discharge from a special psychiatric hospital. Documentation submitted shall include, but is not limited to:</text>
      <paragraph num="(a)">
        <text>The participant’s complete medical record;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The principal, secondary, and tertiary diagnoses; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>All relevant procedure codes.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Reviews for Nonqualified Aliens. The Department or its designee reviews the admission and discharge summary of an emergency inpatient admission for a nonqualified alien to determine whether the inpatient special psychiatric hospital stay meets the emergent condition criteria as defined in COMAR 10.09.24.05-2A.</text>
  </paragraph>
</regulation>