Iowa Admin. Code r. 441-79.10

Current through Register Vol. 47, No. 8, October 30, 2024

Rule 441-79.10 - Requests for preadmission review

The inpatient hospitalization of Medicaid recipients is subject to preadmission review by the Iowa Medicaid enterprise (IME) medical services unit as required in rule 441-78.3 (249A).

(1) The patient's admitting physician, the physician's designee, or the hospital will contact the IME medical services unit to request approval of Medicaid coverage for the hospitalization, according to instructions issued to providers by the IME medical services unit and instructions in the Medicaid provider manual.

(2) Medicaid payment will not be made to the hospital if the IME medical services unit denies the procedure requested in the preadmission review.

(3) The IME medical services unit shall issue a letter of denial to the patient, the physician, and the hospital when a request is denied. The patient, the physician, or the hospital may request a reconsideration of the decision by filing a written request with the IME medical services unit within 60 days of the date of the denial letter.

(4) The aggrieved party may appeal a denial of a request for reconsideration by the IME medical services unit according to 441-Chapter 7.

(5) The requirement to obtain preadmission review is waived when the patient is enrolled in the managed health care option known as patient management and proper authorization for the admission has been obtained from the patient manager as described in 441-Chapter 73.

This rule is intended to implement Iowa Code section 249A.4.

Iowa Admin. Code r. 441-79.10

Adopted by IAB January 06, 2016/Volume XXXVIII, Number 14, effective 1/1/2016