Alerts

Utilization Review Policy

6/21/2010

To: All In-State and Border Hospital Providers

Effective for admissions on or after July 1, 2010, Medicaid will require hospitals to report dates that do not meet InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy on the UB-04 claim form. The following is approved policy that will be a part of Medicaid’s Billing Manual and Administrative Code.

Utilization Review for Inpatient Hospital Admissions and Concurrent Stays

Medicaid will utilize Alabama Medicaid Adult and Pediatric Inpatient Care Criteria (SI/IS) for utilization review, billing and reimbursement purposes.

• It is the hospital’s responsibility to utilize its own physician advisor.

• The attending physician and/or resident may change an order up to 30 days after discharge, as long as the patient met criteria for inpatient or observation services.

For admissions and continued stays on or after July 1, 2010, Medicaid will require in-state and border hospital providers to report dates of service that do not meet InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy.

Dates of service that do not meet InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy must be reported on the UB-04.

• Hospital Providers are required to use Occurrence Span Code 74 to identify days not meeting InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy, and

• Must enter the occurrence span dates for the dates that do not meet InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy.

Inpatient psychiatric and rehabilitation services in an acute care facility will be exempt from reporting dates of service that do not meet InterQual® Adult and Pediatric Medical Criteria and Alabama Medicaid Local Policy.

The Alabama Medicaid Local Policy is available on the Alabama Medicaid website at www.medicaid.alabama.gov under Programs/Hospital Services. Hospital providers are to use the 2009 criteria until the 2010 criteria have been reviewed.

A percentage of admissions and concurrent stay charts will be reviewed by the Alabama Medicaid Agency and a Quality Improvement Organization contracted by the Agency.

All in-state and border hospitals must submit Medical Care Evaluation (MCE) Studies (i.e. Performance Improvement Studies) and Utilization Review (UR) Plans to the contracted Quality Improvement Organization every year upon request.

A document with frequently asked questions has been posted on the Agency’s website under Programs/Hospital Services. Questions regarding this notice should be directed to Jerri Jackson at 334-242-5630 or Karen Smith at 334-353-4945.