Continued Stay Reviews. Continued stay reviews are subsequent reviews performed to determine if continuation of services is medically necessary and appropriate.
Continued Stay Reviews. The Contractor shall have the capability and established procedures to receive Continued Stay Reviews requests for additional inpatient days of care for admissions previously certified and conduct prior authorizations on or before the next review point (i.e. the last certified day). The Contractor shall ensure determinations for Continued Stay Reviews are completed ninety-eight percent (98%) of the time within twenty- four (24) hours (one workday) of receipt when Members remain hospitalized and within twenty-four (24) hours (one workday) when Members have been discharged.
Continued Stay Reviews. Any individual involuntarily admitted to Tyler 4 will be reviewed by State Utilization Review Care Manager. Continued Stay Review will be determined by the DMH Utilization Review Care Manager. The Contractor will provide clinical information requested by the Utilization Reviewer to authorize the period of inpatient care during the period of time under review. Any continued stay review that appears to no longer meet inpatient or Level I patient clinical eligibility criteria will be referred to the State Care Manager assigned to the DMH for concurrent review. Only after consultation between the DMH Care Manager and review between the DMH Utilization Review Care Manager with the DMH utilization review representative, a continued stay determination will be made. The DMH Utilization Review Care Manager in consultation with the DMH Medical Director or Psychiatrist designee will: • certify the continued stay as Level I involuntary • certify the continued stay as acute, voluntary or involuntary, and identify the continued stay review periodicity; or • certify the continued stay as “awaiting discharge” level of care and the basis for the determination; or • certify no inpatient level of care being met and issue payment denial. For DMH tracking purposes with Level I inpatient providers, and evaluation of Level I inpatient bed utilization for annual real, actual cost reconciliation, the aforementioned certifications for Continued Stay Reviews will: • Authorize Level I clinical eligibility criteria as being met and identify subsequent continued stay review date. Continuing Level I enhanced payment clinical eligibility criteria will consider intensity and duration of treatment services and routine documentation of: ▪ The need for continued allocation of significant and more than usual resources to maintain the safety of the patient, other patients, or staff; ▪ intractable mental illness symptomology, ongoing behavioral dysregulation and instability with demonstrated treatment plan modifications; ▪ complex medication management that must occur in an acute inpatient setting; ▪ active daily restorative interventions/services not available in alternate level of care settings. This authorization level maintains enhanced payment for inpatient billing and coding purposes; or • Authorize “acute” level of care (Level I patient remains acute, no longer requires additional Level I resources, and internal transfer to other units is possible*) and effective date. This authorization...
