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2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3. Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.6 Inpatient Utilization Review : 3.6.3 Hospitals Reimbursed Under Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982

3.6.3
For all Medicaid admissions identified for review, the TEFRA review process consists of the following major components:
Admission review. Determination of the medical necessity of the admission. For purposes of the TMRP and TEFRA, medical necessity means the client has a condition requiring treatment that can be safely provided only in the inpatient setting.
Continued stay review. Determination of the medical necessity of each day of stay.
Quality of care review. Assessment of the quality of care provided to determine if it meets generally accepted standards of medical and hospital care practices or puts the client at risk of unnecessary injury or death. Quality of care review includes the use of discharge screens and generic quality screens.
TEFRA hospitals are required to submit all charges.
HHSC OIG UR Unit staff review the complete medical record to make decisions about the medical necessity of the admission, continued stay, and quality of care.

Texas Medicaid & Healthcare Partnership
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