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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility) : 3.6 Utilization Review Process : 3.6.1 Admission Review

3.6.1
All services, supplies, or items submitted as certified on claim submission, must be medically necessary for the client’s diagnosis or treatment. Review personnel assess the medical necessity of an admission by comparing documentation present in the medical record using recognized evidence-based guidelines for inpatient screening criteria. The evidence-based guidelines are Milliman Care Guidelines, which replace the physician developed and physician-approved Medicaid hospital screening criteria addressed through a rule revision effective August 1, 2006. Non-physician reviewers use the criteria as guidelines for the initial approval or for the referral of inpatient reviews for medical necessity decisions. Cases that do not meet initial approval are referred to a physician consultant to determine the medical necessity of the inpatient admission. If the criteria are met but the medical necessity of the admission is still questionable, the case is referred to a physician consultant for a determination. If a physician consultant determines the admission is not medically necessary, a denial is issued.
Review personnel assess the medical necessity of admissions prior to September 1, 2006, by comparing documentation present in the medical record with elements in the TMRP Hospitalization Screening Criteria.

Texas Medicaid & Healthcare Partnership
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