471 Neb. Admin. Code, ch. 31, § 006

Current through June 17, 2024

Section 471-31-006 - UTILIZATION REVIEW

Utilization reviews (UR) of Nebraska Medicaid clients residing in an intermediate care facility for individuals with developmental disabilities (ICF/DD) are conducted by the Medicaid review team to determine if clients continue to meet intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care. The utilization review (UR) also evaluates the effectiveness of services provided to clients by intermediate care facilities for individuals with developmental disabilities (ICF/DD). Utilization reviews (UR) will occur at least every six months. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must retain documentation of the utilization review (UR) in the client's permanent record.

006.01MEDICAID REVIEW TEAM.

006.01(A)MEDICAID REVIEW TEAM RESPONSIBILITIES. The Medicaid review team will:

(1) With input from facility staff as needed, establish a utilization review (UR) schedule for each intermediate care facility for individuals with developmental disabilities (ICF/DD);

(2) Notify the facility of the utilization review (UR) at least 30 days prior to the review;

(3) Provide the facility a listing of the clients that are reviewed;

(4) Provide direction to the facility regarding forms and records required for the review:

(5) Determine whether each client is approved for a continued stay for a maximum of six months or does not meet criteria for a continued stay. When a continued stay is not approved, follow the appropriate procedures: and

(6) Notify the facility of the results of the utilization review (UR).

006.01(A)(i)EXPANSION OF REVIEW PROCESS. The Medicaid review team has the authority to expand the review process as needed and may include the review of additional client records, and interviews with clients and facility staff. In the event the Medicaid review team determines the documentation available for review does not provide adequate information to make a determination of whether the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate, the Medicaid review team may conduct onsite observations and interview with the client at the facility, interview facility staff, and request additional information from the intermediate care facility for individuals with developmental disabilities (ICF/DD).

006.01(B)INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). Within 10 days following receipt of the utilization review results the intermediate care facility for individuals with developmental disabilities (ICF/DD) must respond to the department in writing, and must include the following information:

(1) A complete plan of correction that addresses all identified findings and recommendations:

(2) Changes in level of care;

(3) Each individual recommendations and the examples of problems: and

(4) Projected dates of completion on each of the above.

006.01(B)(i)FAILURE TO RESPOND. If the facility fails to submit a timely and/or appropriate response, the Department may take administrative sanctions or any of the following actions.

(a) The Department may suspend Title XIX reimbursement for a client or the entire reimbursement for the facility: or

(b) Clients may be transferred to another facility.

006.01(C)COMPOSITION OF THE MEDICAID REVIEW TEAM. The Medicaid review team must include a Medicaid reviewer who is knowledgeable in working with individuals with developmental disabilities and related conditions. The team may also include any of the following:

(1) A physician:

(2) A registered nurse: and

(3) Other professional personnel as needed based on the review process.

006.01(C)(i)PHYSICIAN. The Department is the final authority for findings, patient care recommendations, and official action.

006.01(C)(ii)REGISTERED NURSE. The registered nurse may consult and participate in the utilization review (UR) process, should there be potential issues related to nursing or medical services.

006.01(C)(iii)OTHER PROFESSIONAL PERSONNEL. Other professional personnel may consult and participate in the utilization review (UR) process, based on their expertise related to services in which the Medicaid review team identified possible issues.

471 Neb. Admin. Code, ch. 31, § 006

Amended effective 12/26/2021