Idaho Admin. Code r. 16.03.09.405, Inpatient Hospital Services: Provider Reimbursement

Establishes standards and procedures for Medicaid reimbursement of inpatient hospital services. Requires a Medicaid participant’s admission and length of stay in an inpatient hospital to receive prior authorization and undergo concurrent review, continued stay review, and a retrospective review by a designated Quality Improvement Organization (QIO). Bars payments for services that a review determines were not medically necessary. Imposes a penalty on payments for services that did not undergo QIO review within a timely manner. Permits hospitals to appeal QIO decisions in accordance with IDAPA 16.05.03. Requires hospitals to allow the Department of Health and Welfare to access records necessary to administering the Medicaid program.