Acute Inpatient Administrative Days



Policy/Procedure Number: MCUP3053 (previously UP100353)Lead Department: Health ServicesPolicy/Procedure Title: Acute Inpatient Administrative Days?External Policy ? Internal PolicyOriginal Date: 06/20/2001Next Review Date:02/12/2021Last Review Date:02/12/2020Applies to:? Medi-Cal? EmployeesReviewing Entities:? IQI? P & T? QUAC? OPerations? Executive? Compliance? DepartmentApproving Entities:? BOARD? COMPLIANCE? FINANCE? PAC? CEO? COO? Credentialing? DEPT. DIRECTOR/OFFICERApproval Signature: Robert Moore, MD, MPH, MBAApproval Date: 02/12/2020RELATED POLICIES: MCUG3024 - Inpatient Utilization Management IMPACTED DEPTS: Health Services,Member ServicesClaimsDEFINITIONS: Acute administrative days - are those days approved at an acute inpatient facility, which provide 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). ATTACHMENTS: N/APURPOSE: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.POLICY / PROCEDURE: 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 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. 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 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 at the present timeIf the member is pending placement at a level of care that is not PHC’s responsibility, administrative days do not apply. Examples include, but are not limited to, members awaiting placement at a mental health facility, members awaiting evaluation on a psychiatric hold or members who are the responsibility of the criminal justice system.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.The acute facility must initiate placement efforts prior to the termination of acute care coverage and shall document such efforts and contacts.The acute inpatient facility must call potential placement facilities within a 60 miles radius daily to attempt to place any particular member. Factors considered in determining the number of daily calls to be made in each specific case include:The availability of SNF/ICF beds in the geographical area The number of TC providers in the area, andThe number of SNF/ICF’s in the geographical area staffed to meet the needs of membersThe calls made can cover more than one member being placed provided that:The acute inpatient facility staff document in each member record the attempted placement callThe SNF/ICF can meet the special needs of a particular memberThe 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.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. PHC will apply administrative days in accordance with the facility’s individual contract.REFERENCES: Medi-Cal GuidelinesDISTRIBUTION: PHC Provider ManualPHC Department DirectorsPOSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health ServicesREVISION DATES: Medi-Cal05/15/02; 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; 02/13/19; 02/12/20*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 processesEvaluated and updated at least annuallyIf 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 requestThe 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. ................
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