section .0200 inpatient hospital services



(a) Private and semi‑private rooms shall be reimbursed only when medically necessary (or when a census makes it necessary). Claims must be supported by a physician's statement.

(b) Medical necessity for acute hospital level‑of‑care and length of stay will initially be determined by a hospital's Utilization Review Committee; however this need will be subject to post‑payment review by the state agency. All claims will be subject to prepayment review for Medicaid coverage.

(c) The State agency may grant a maximum of three administrative days to arrange for discharge of a patient to a lower level‑of‑care. With prior approval by the State Medicaid agency, the hospital may be reimbursed for days in excess of the three administrative days at the statewide average rate for the particular level of care needed in the event a lower level‑of‑care bed in a Medicaid approved health care institution is not available. The hospital must, however, make every effort to place the recipient in an appropriate institution within the three-day administrative time allowance.

(d) Preadmission Authorization

(1) Preadmission authorization to admit a Medicaid patient for elective acute hospital level of care is required by the State Agency in accordance with physician developed criteria except under the following conditions:

(A) Medicare is a primary payor; or

(B) The admission is for a delivery; or

(C) The patient is determined Medicaid eligible after admission has occurred.

(2) The admitting physician is responsible for securing the authorization. A denial to authorize the admission may be appealed by the physician, or hospital. Failure to secure authorization shall result in denial or recoupment for any inappropriate or unnecessary admission.

(3) The State Agency will establish Administrative mechanisms to evaluate request for retroactive approvals to consider cases where either events occurred that were outside the provider's control or technical processing errors prevented obtaining an authorization prior to the patient's being admitted to the hospital.

(4) In all cases involving a denial or recoupment, neither the hospital nor practitioner may bill the patient.

(e) Inpatient care in North Carolina state specialty hospitals of persons with pulmonary or chronic diseases shall be covered.


History Note: Authority G.S. 108A‑25(b); 108A‑54; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.10; 42 C.F.R. 440.230(d); 42 C.F.R.447.253; 42 C.F.R. 456.1;

Eff. February 1, 1976;

Readopted Eff. October 31, 1977;

Amended Eff. October 1, 1986; August 1, 1986; October 1, 1982;

Temporary Amendment Eff. October 15, 1999;

Temporary Amendment Expired July 28, 2000;

Temporary Amendment Eff. September 25, 2000;

Temporary Amendment Expired June 29, 2001;

Paragraphs (a)-(d) transferred from 10A NCAC 22O .0401 Eff. May 1, 2012.

Paragraph (e) transferred from 10A NCAC 22O .0114 Eff. May 1, 2012 (Previously recodified from 10 NCAC 26B .0112 Eff. October 1, 1993 and recodified from 10 NCAC 26B .0113 Eff. January 1, 1998).