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Hospital
18.1 Enrollment 18-3
18.1.1 Hospital 18-3
18.1.2 Continuity of Hospital Eligibility Through Change of Ownership 18-3
18.1.3 Hospital-Based and Freestanding Ambulatory Surgical Centers 18-3
18.1.4 Specialty Team or Center 18-4
18.1.5 Inpatient Behavioral Health Enrollment 18-4
18.2 Reimbursement 18-4
18.2.1 Hospital Reimbursement 18-4
18.2.2 Inpatient 18-4
18.2.2.1 Stem Cell Transplant Reimbursement and Facility Requirements 18-4
18.2.2.2 Renal Transplants Reimbursement and Facility Requirements 18-5
18.2.2.3 Inpatient Behavioral Health Reimbursement 18-5
18.2.2.4 Hospital Laboratory Services 18-5
18.2.3 Outpatient 18-6
18.2.3.1 Blood Factor Products 18-6
18.2.3.2 Hospital-Based Emergency Department Services 18-6
18.2.4 Ambulatory Surgical Centers (Hospital-Based and Freestanding) 18-7
18.2.4.1 Freestanding Surgical Centers 18-7
18.2.4.2 Complications Resulting in Medically Necessary Stays Following
Scheduled Day Surgeries 18-7
18.2.4.3 Complications Following Unscheduled (Emergency) Day Surgeries 18-7
18.2.5 Laboratory 18-8
18.2.6 Radiology 18-8
18.3 Benefits and Limitations 18-8
18.3.1 Inpatient Hospital 18-8
18.3.1.1 Stem Cell Transplants 18-9
18.3.1.2 Renal Transplants 18-9
18.3.1.3 Inpatient Behavioral Health Benefits and Limitations 18-9
18.3.1.4 Cochlear Implants 18-9
18.3.2 Inpatient Rehabilitation Services 18-9
18.3.2.1 Exceptions 18-10
18.3.3 Outpatient Services 18-10
18.3.3.1 Blood Factor Products 18-10
18.3.3.2 Cochlear Implants 18-11
18.3.3.3 Hospital-Based Emergency Services Department 18-11
18.3.4 Outpatient Observation 18-11
18.3.5 Hospital Radiation Therapy and Radiology Services 18-12
18.4 Authorization Requirements 18-12
18.4.1 Inpatient Hospital Services (Prior) Authorization Requirements 18-13
18.4.1.1 Initial Inpatient Requests 18-13
18.4.1.2 Emergency Inpatient Hospital Admissions 18-13
18.4.1.3 Inpatient Hospital Extensions 18-13
18.4.1.4 Inpatient Behavioral Health Prior Authorization Requirements 18-13
18.4.1.5 All Hospital Authorization Requests 18-14
18.4.1.6 Renal Transplants 18-14
18.4.2 Inpatient Rehabilitation Prior Authorization Requirements 18-14
18.4.3 Ambulatory Surgery Authorizations 18-15
18.5 Claims Information 18-15
18.5.1 Inpatient Behavioral Health Claims Information 18-16
18.5.2 Freestanding Surgical Center Claims 18-16
18.5.3 Hospital-Based Surgical Center Claims 18-16
18.6 TMHP-CSHCN Services Program Contact Center 18-17
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