Acute Care Hospitals

Medical Necessity Review

KePRO performs medical necessity review for all Medicaid patients having hospitalizations within the state of Maryland and the contiguous states of Pennsylvania, Virginia, and Delaware. Hospitalizations for Maryland Medicaid beneficiaries in states other than those listed above are reviewed by DHMH, Division of Acute and Professional Services, 201 W. Preston Street, Baltimore, Maryland 21202.

KePRO performs 3 types of reviews:

• Preauthorization of Elective Admissions (medical necessity review for Medicaid patients who have scheduled inpatient admission.)
• Concurrent (medical necessity review for Medicaid patients who have Medicaid at the time of admission and do not have a planned inpatient admission.) Concurrent review applies to all emergency admissions for initial review and subsequent stay review of elective admissions if patient is still hospitalized.
• Retrospective (validation of the facility’s description and coding of principal, secondary and tertiary diagnoses and all surgical procedures as well as medical necessity.)

Clinical submission timeframes

Submission of clinical information for elective admissions is required at least 48 hours prior to the planned admission.

Clinical information for elective admissions includes the following:

• Patient MA # and verification date (Note: although prior authorization is obtained, all providers must verify eligibility on the day of admission)
• Diagnosis
• Planned procedure
• Date of admission
• Indication for procedure (symptomatology /reason procedure is being done)
• # of days requested
• Contact information of requestor

Upon approval of the elective admission, no further information is requested unless the patient’s inpatient stay exceeds the number of days given by KePRO during the prior authorization process. If this occurs, the information is to be submitted following the submission timelines for concurrent review.

Concurrent Review

Concurrent review applies to all emergency admissions for initial review and subsequent stay review of elective admissions if patient is still hospitalized. The submission of clinical information during concurrent review is provided in the Concurrent Review Letter.

To receive medical necessity expeditiously, only submit information that explains why the patient has been hospitalized and the care rendered that is relevant to the admission reason. All care that is submitted should be linked to an abnormality that necessitates the care given. For example, O2 at 2L needs to be accompanied by pulse ox reading, PAO2 determination or some other symptom or objective clinical finding consistent with the need for oxygen administration.

Follow the schedule for submission of clinical information until discharge. Once discharge occurs, enter the discharge date into iEXCHANGE.

Retrospective Review

Retrospective review is conducted when a hospital submits a DHMH 3808 in the following situations:

• Retrospective Eligibility Review - When a recipient has been found financially eligible for Medicaid Fee For Service (FFS) benefits subsequent to the admission date; or
• Retrospective (3808 Processing) - Recipients who have had authorization and/or concurrent review during the admission. KePRO validates the facilities description and coding of principal, secondary and tertiary diagnoses and all surgical procedures and medical necessity.
• Submission of clinical information occurs after discharge and should include each day of the admission.

KePRO will not perform a medical necessity review on any elective (non-emergency) admission that has not been preauthorized by KePRO. This will result in a technical denial of the entire stay.

Medical Necessity Determinations

KePRO determines medical necessity using InterQual Acute Care criteria. These criteria have two areas of focus:

• Severity of Illness (what symptoms or objective clinical data did the patient demonstrate that lead to admission) and;
• Intensity of Service (what care was provided relative to the reason for admission and each subsequent day that justifies the need for hospitalization)

Additional information such as consultations or procedures that are not linked with the reason for the hospitalization or continued stay are not considered by InterQual criteria to justify hospitalization. Clinical nurse reviewers can best review and apply the InterQual criteria when the information submitted is directly related to the severity of illness and intensity of service upon admission and the intensity of service for each subsequent day after admission. If the diagnosis or reason for admission changes severity of illness is reviewed. Questions regarding submission of clinical information and review type can be referred to Linda Gregory at ext. 3004.

Administrative Days

Administrative days are requested by hospital providers when the patient is clinically stable for discharge but for some non-medical reason, the patient is not discharged. Rather than have these days denied for lack of medical necessity, the hospital has the prerogative to request administrative days. A facility must submit the request for administrative days using the DHMH Form 1288. Administrative days must be requested by completion of the Form 1288 at the time that the 3808 is submitted.

Reconsiderations

In the event that a hospital receives a denial of days, the hospital has the right to request a reconsideration. Reconsideration requests must be received within 30 days of the date on the denial letter. Requests for reconsideration after days of the denial date will remain denied due to lack of timely filing. When requesting a reconsideration, the facility sends a letter detailing the rationale for why the days should be considered for payment and pertinent portions of the medical record.

KePRO – Reconsideration
11350 McCormick Road, Suite 102
Executive Plaza II
Hunt Valley, Maryland 21031

Corrections

On occasion, facilities learn that information submitted in a case needs to be changed or corrected. When this occurs, submit the correction or change via iEXCHANGE. KePRO will validate the correction request submitted by the provider. Upon completion the correction will be sent to DHMH to be updated in the State's System. KePRO documents a note in iEXCHANGE to let the provider know that the change has been processed.