Minnesota Administrative Rules

9505.0300 INPATIENT HOSPITAL SERVICES.

Subpart 1.

Definition.

"Inpatient hospital service" means a health service provided to a recipient who is an inpatient.

Subp. 2.

Eligibility for participation in medical assistance program; general.

To be eligible for participation in the medical assistance program, a hospital must meet the conditions of items A to C.

A.

Be qualified to participate in Medicare, except as in subpart 4.

B.

Have in effect a utilization review plan applicable to all recipients. The plan must meet the requirements of the Code of Federal Regulations, title 42, section 405.1035 and part 456, unless a waiver has been granted by the secretary of the United States Department of Health and Human Services. The hospital's utilization review plans must ensure a timely review of the medical necessity of admissions, extended duration stay, and health services rendered.

C.

Comply with the requirements of the Code of Federal Regulations, title 42, concerning informed consent for a voluntary sterilization procedure under section 441.257 and for a hysterectomy, under section 441.255, and for the documentation for abortion, under sections 441.205 and 441.206.

Subp. 3.

Payment limitation.

Payment for inpatient hospital services to a recipient shall be made according to parts 9500.1090 to 9500.1140. Inpatient hospital services that are medically necessary for treatment of the recipient's condition are not eligible for a separate payment but are included within the payment rate established under parts 9500.1090 to 9500.1155. An example of a medically necessary service is a private room that the recipient's physician certifies as medically necessary.

Subp. 4.

Eligibility for participation in medical assistance; emergency.

A hospital service provided to a recipient in an emergency is eligible for medical assistance payment regardless of whether the hospital providing the service is qualified to participate in Medicare. Urgent care services do not qualify for medical assistance payment under this subpart. For the purposes of this subpart, "urgent care" means acute, episodic care similar to services provided in a physician directed clinic.

Subp. 5.

Excluded services.

Inpatient hospital admission and services are not eligible for payment under the medical assistance program if they are not medically necessary under parts 9505.0501 to 9505.0545; if they are for alcohol detoxification that is not medically necessary to treat an emergency; if they are denied a required prior authorization; or if they are surgical procedures requiring a second surgical opinion that has failed to be approved by a second or third surgical opinion.

Statutory Authority:

MS s 256B.04

History:

12 SR 624

Published Electronically:

January 14, 2010