Inpatient hospital admissions must be pre-certified as medically necessary by the MO HealthNet Division (MHD) review authority, Xerox Care and Quality Solutions. In addition to precertification of inpatient stays, Xerox's responsibilities include validation reviews described in 13 CSR 70-15.020(9) and in Section 13.29.F(5) of the MO HealthNet hospital provider manual available at: http://manuals.momed.com/manuals/.
Xerox Care and Quality Solutions requests records on a quarterly basis for validation reviews, which confirms that the information provided at the time of the certification request is consistent with the documentation and clinical findings in the medical record. Xerox selects a statistically valid sampling of certifications from each hospital which includes certified admissions and continued stay reviews. Xerox performs a utilization and quality of care review on those admissions chosen in the sampling. All admissions may be subject to focused validation review if a potential quality of care issue was identified by the nurse reviewer.
For admissions subject to review, Xerox requests medical records. Providers have 30 calendar days from the date of request to submit documentation. Records not received within the 30 calendar days may result in the admission being denied and or the claim being recouped for payment. A validation review determination that an inpatient stay was not medically necessary results in recovery of MHD payments in accordance with state regulation 13 CSR 70-3.030. Overpayment determinations may be appealed to the Administrative Hearing Commission.