Ga. Medicaid Part II Policies & Procedures for Hospital Services § 801

As a condition of Reimbursement, the Division requires that Inpatient Hospital admissions and

certain outpatient procedures be prior approved or pre-certified. Precertification pertains to medical

necessity and appropriateness of setting only; the patient must be eligible at the time the service is

rendered. The purpose of the program is to ensure that medically necessary quality health-care

services be provided to eligible Medicaid members in the most cost-effective setting. Precertification

does not guarantee reimbursement. The medical record must substantiate the medical necessity

including the appropriateness of the setting for the services provided and billed to the Division.

All services regardless of certification are subject to review for medical necessity. (See

Part I, Sections 106.12 and 204.)

Deliveries, Newborns (birth), and members who ha ve Medicare P art A are not subject to

precertification. Once a newborn has been d ischarged from the initial birth hospital stay,

Precertification is required for all subsequent admissions.

Newborns remaining hospitalized more than 30 days continuously from the date of birth require

precertification beginning the 31st day of that hospital stay.

For dates of service October 1, 1993, through June 30, 1995, Cesarean section deliveries at certain

hospitals will be exempt from precertification requirements. To qualify for this exemption, the

hospital must perform at least one hundred Medicaid paid deliveries in the calendar year.

Additionally, the number of Medicaid paid cesarean section deliveries

must have been no more than twenty percent of the hospital’s total Medicaid paid deliveries

for the previous calendar year.

As a condition of reimbursement, emergency admissions must be certified within thirty calendar days

after admission (see Section 903.6). Inpatient hospital admissions for post delivery services must be

pre-certified when a delivery procedure cannot be coded on the hospital claim form; e.g., delivery at

home, delivery enroute to the hospital, etc.

Appendix D provides detailed information regarding specific outpatient procedures that must be

certified prior to the time they are performed. Emergency outpatient services and Urgent outpatient

procedures performed as a result of a condition which, if not treated within 48 hours, would result in

significant alteration in the member’s health status, must be certified within thirty (30) calendar days

of the date of the procedure.

NOTE: FAILURE TO OBTAIN THE REQUIRED CERTIFICATION WILL RESULT IN

DENIAL OF REIMBURSEMENT.