Policy/Procedure Title: Acute Inpatient Administrative Days / ☒ External Policy
☐ Internal Policy /
Original Date: 06/20/2001 / Next Review Date: 02/14/2019
Last Review Date: 02/14/2018 /
Applies to: / ☒ Medi-Cal / ☐ Employees /
Policy/Procedure Number: MCUP3053 (previously UP100353) / Lead Department: Health Services /
Policy/Procedure Title: Acute Inpatient Administrative Days / ☒External Policy
☐ Internal Policy /
Original Date: 06/20/2001 / Next Review Date: 02/14/2019
Last Review Date: 02/14/2018 /
Applies to: / ☒ Medi-Cal / ☐ Employees /
Reviewing Entities: / ☒ IQI / ☐ P & T / ☒ QUAC /
☐ OPerations / ☐ Executive / ☐ Compliance / ☐ Department /
Approving Entities: / ☐ BOARD / ☐ COMPLIANCE / ☐ FINANCE / ☒ PAC
☐ CEO / ☐ COO / ☐ Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA / Approval Date: 02/14/2018
I. RELATED POLICIES:
MCUG3024 - Inpatient Utilization Management
II. IMPACTED DEPTS:
A. Health Services,
B. Member Services
C. Claims
III. DEFINITIONS:
Acute administrative days - are those days approved at an acute inpatient facility, which provides a higher level of medical care than that currently needed by the member or when members are awaiting placement in transitional inpatient care (TC) units, skilled nursing facilities (SNFs) or intermediate care facilities (ICFs).
IV. ATTACHMENTS:
A. Notification of Acute Inpatient Administrative Days
V. PURPOSE:
To define the circumstances under which Partnership HealthPlan of California (PHC) authorizes administrative days for inpatient hospitals where there is a contracted administrative day rate in place between PHC and the acute care facility.
VI. POLICY / PROCEDURE:
A. A PHC member may be approved for subacute administrative days when, after review of information from the attending physician and the medical record, it is the professional judgment of the PHC Chief Medical Officer or physician designee that the following circumstances exist:
1. Member’s care no longer meets acute inpatient criteria, but does require lower level inpatient care such as long-term acute care (LTAC) or subacute care.
B. A PHC member may be approved for acute inpatient administrative days when, after review of information from the attending physician and the medical record, it is the professional judgment of the PHC Chief Medical Officer or physician designee that either of the following circumstances exist:
1. The member’s care required exceeds the level of care available in SNFs and ICFs in the community, but the member’s condition does not require acute inpatient care.
2. The medical and nursing care required is at a level of care available in SNFs and ICFs in the community, but placement is not available.
C. Administrative days for TC, SNF, or ICF care members are authorized subject to appropriate and timely discharge, and are authorized only until such time that the needs of the member change to SNF/ICF level or appropriate placement becomes available.
D. The acute facility must initiate placement efforts prior to the termination of acute care coverage and shall document such efforts and contacts.
1. The Director of Health Services has the authority to determine the number of facilities that the acute inpatient facility must call daily to place any particular member. Factors considered in determining the number of daily calls to be made in each specific case include:
a. The availability of SNF/ICF beds in the geographical area
b. The number of TC providers in the area, and
c. The number of SNF/ICF’s in the geographical area staffed to meet the needs of members
E. The calls made can cover more than one member being placed provided that:
1. There is documentation in the record that each member was discussed as a placement possibility
2. The SNF/ICF can meet the special needs of a particular member
3. The acute inpatient facility must continue placement efforts until placement occurs. The acute inpatient facility may be required to submit its documentation to the PHC Nurse Coordinator.
F. This policy does not apply to facilities that do not have contracted “administrative day” rates with PHC. For these facilities, the medical necessity of continued stay at the acute care facility is determined by criteria as specified in the Inpatient Utilization Management policy MCUG3024.
VII. REFERENCES:
Medi-Cal Guidelines
VIII. DISTRIBUTION:
A. PHC Provider Manual
B. PHC Department Directors
IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
X. REVISION DATES:
Medi-Cal
05/15/02; 05/21/03; 10/20/04; 10/19/05; 10/17/07; 10/15/08; 05/18/11; 09/17/14; 01/21/15; 01/20/16; 01/18/17; *02/14/18
*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.
PREVIOUSLY APPLIED TO: N/A
*********************************
In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:
· Consistent with sound clinical principles and processes
· Evaluated and updated at least annually
· If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request
The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.
PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910.
Page 3 of 3