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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUtah Medicaid Leave Payment Policy Update | OpenPa…
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    CurrentUtah MedicaidPolicy 24-0023

    Reserve Bed Payment Policy — Leave of Absence

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    This policy governs Utah Medicaid payment to Title XIX-certified nursing facilities and intermediate care facilities for individuals with intellectual disabilities when residents are temporarily absent for hospitalization, therapeutic or rehabilitative leave, or personal or family reasons.

    Policy Summary
    PayerUtah Medicaid
    PolicyReserve Bed Payment Policy — Leave of Absence
    Policy CodePolicy 24-0023
    Change TypeNo material change
    Effective DateJanuary 1, 2025
    Next Review DateNot specified
    Key ActionObtain prior approval from the Division of Integrated Healthcare before requesting payment for therapeutic or rehabilitative leave days exceeding the applicable annual limit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 daysNF annual therapeutic or rehabilitative leave limit
    100 daysICF/IID annual therapeutic or rehabilitative leave limit
    No paymentPayment for hospital bed-hold days
    All daysLeave days reported on claims
    Prior approvalApproval for additional leave days

    Leave of Absence Payment Criteria

    Nonpayable and recoupable leave

    Certain leave days are not payable, and excessive payments may be recouped.

    ONE of

    • The NF or ICF/IID bed is held while the resident is temporarily in a hospital. Payment is not made for the hospital stay bed-hold days; payment is available for the facility admission day but not the day of discharge to the hospital.
    • The leave is unauthorized personal or family leave. Medicaid cannot pay for unauthorized leave days.
    • The Department of Health and Human Services determines, after reviewing resident records, that leave days were excessive; payments made for those days must be returned.

    Leave Limits and Reporting Definitions

    Policy Summary
    PayerUtah Medicaid
    PolicyReserve Bed Payment Policy — Leave of Absence
    Policy CodePolicy 24-0023
    Change TypeNo material change
    Effective DateJanuary 1, 2025
    Next Review DateNot specified
    Key ActionObtain prior approval from the Division of Integrated Healthcare before requesting payment for therapeutic or rehabilitative leave days exceeding the applicable annual limit.
    SourceLink
    On This Page
    Leave of Absence Payment CriteriaLeave Limits and Reporting DefinitionsProvider and Billing RequirementsPolicy Definitions

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    Nursing Facility Leave Limit
    Facility typeNursing facility (NF)
    Payment categoryTherapeutic or rehabilitative leave of absence
    Annual limit12 days per calendar year for each resident of a NF
    ICF/IID Leave Limit
    Facility typeIntermediate care facility for individuals with intellectual disabilities (ICF/IID)
    Payment categoryTherapeutic or rehabilitative leave of absence
    Annual limit100 days per calendar year for each resident of an ICF/IID
    Leave of Absence Day
    Qualifying purposesTherapeutic, rehabilitative, or hospitalization purposes
    Return conditionThe resident does not return to the inpatient facility by midnight on the same day
    Plan-of-care requirementLeave for a purpose other than required hospitalization must be documented in and consistent with the resident's plan of care

    Provider and Billing Requirements

    Prior Authorization

    Request prior approval for additional leave days

    Obtain prior approval from the Division of Integrated Healthcare before requesting payment for therapeutic or rehabilitative leave days exceeding the applicable annual limit.

    • Nursing facility: more than 12 days per calendar year for each resident.
    • ICF/IID: more than 100 days per calendar year for each resident.
    Documentation Required

    Document additional leave authorization

    Accompany the prior approval request with appropriate and adequate documentation and written approval of the additional leave days by the resident’s physician and/or interdisciplinary team, as appropriate, to meet and support the resident’s plan of care.

    • Include the required physician and/or interdisciplinary team approval.
    • Retain documentation supporting the resident’s plan of care.
    Documentation Required

    Document therapeutic or rehabilitative leave

    Support every therapeutic or rehabilitative leave of absence with a written order from the resident’s physician. Document the leave appropriately and adequately in the resident’s progress notes and identify it as rehabilitative leave that meets and supports the resident’s plan of care.

    • Obtain a written physician order.
    • Record the leave in the resident’s progress notes.
    • Ensure the physician and/or interdisciplinary team identifies the leave as rehabilitative leave.
    Billing Rule

    Apply hospitalization bed-hold payment rule

    Do not bill or expect payment for days on which an NF or ICF/IID bed is held while the resident is temporarily in a hospital. Payment is available for the day of admission to the NF or ICF/IID, but not the day of discharge to the hospital.

    • Hospitalization bed-hold days are not payable.
    • Apply the admission-day exception.
    Documentation Required

    Support hospital leave under DRG

    Under the diagnosis-related group (DRG) reimbursement methodology, hospital leave should seldom be necessary. When granted, document the leave with a written physician’s order and include it in the resident’s progress notes.

    • Obtain a written physician order.
    • Include the leave in the resident’s medical record progress notes.
    Billing Rule

    Report leave days on claims

    Report all leave of absence days on the claim.

    Denial Risk

    Do not restrict resident leave

    Do not prevent a resident from taking personal or family leave solely because the facility will not receive payment, even when the leave cannot be justified as therapeutic or rehabilitative, if the resident wishes to take the leave and the physician agrees.

    Documentation Required

    Notify and document unauthorized leave

    Before unauthorized personal or family leave, advise the resident and/or family that Medicaid cannot pay for the unauthorized leave days. Put any resulting agreement in writing, document knowing, informed, and voluntary consent, and keep the agreement in the resident’s chart for audit.

    • Notify the resident and/or family in advance.
    • Retain the written agreement in the resident’s chart.
    • Ensure the agreement demonstrates knowing, informed, and voluntary consent.
    Denial Risk

    Return excessive leave payments

    Return payments for leave days that the Department of Health and Human Services determines to be excessive after reviewing resident records.

    • The repayment requirement applies to excessive leave identified through record review.

    Policy Definitions

    Leave of Absence Day
    DefinitionA day during which the resident is absent from an inpatient facility
    Qualifying purposesTherapeutic, rehabilitative, or hospitalization purposes
    Midnight requirementThe resident does not return by midnight on the same day
    Documentation requirementLeave for a purpose other than required hospitalization must be documented in and consistent with the resident's plan of care
    Nursing Facility (NF)
    FacilityNursing facility (NF)
    CertificationCertified under Title XIX
    Policy contextThe NF is an inpatient facility subject to reserve bed payment rules when a resident is temporarily absent
    Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)
    FacilityIntermediate care facility for individuals with intellectual disabilities (ICF/IID)
    CertificationCertified under Title XIX
    Policy contextThe ICF/IID is an inpatient facility subject to reserve bed payment rules when a resident is temporarily absent