(1) Prior to admission and as frequently as the department may deem necessary, the department or its agents may evaluate the medical necessity and quality of services for each Medicaid recipient.

(a) In addition to the other requirements of these rules, the provider must provide to the department or its agent upon request any records related to services or items provided to a Medicaid recipient.

(b) The department may contract with and designate public or private agencies or entities or, a combination of public and private agencies and entities, to perform utilization review, inspections of care and other functions under this rule as an agent of the department.

(2) The department or its agents may conduct periodic inspections of care in residential treatment facilities participating in the Medicaid program.

(3) Medicaid reimbursement is not available for inpatient psychiatric services unless the provider submits to the department or its designee in accordance with these rules a complete and accurate certificate of need for services that complies with the requirements of 42 CFR, Part 441, subpart D and these rules.

(a) For recipients determined Medicaid eligible by the department as of the time of admission to the facility, the certificate of need must:

(i) be completed, signed and dated prior to, but no more than 30 days before admission; and

(ii) be made by an independent team of health care professionals that has competence in diagnosis and treatment of mental illness and that has knowledge of the recipient's situation, including the recipient's psychiatric condition. The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, a licensed mental health professional and, for residential psychiatric care, an intensive case manager employed by a mental health center.

(b) For recipients who are transferred between levels of inpatient psychiatric care within the same facility, the certificate of need may be completed by the facility-based team responsible for the plan of care within 14 days after admission provided that the:

(i) certificate of need has been signed by an intensive case manager employed by a mental health center or other individual knowledgeable about local mental health services as designated by the department; and

(ii) admission has been prior authorized by the department or the department's designee.

(c) For recipients determined Medicaid eligible by the department after admission to or discharge from the facility, the certificate of need must:

(i) be completed, signed and dated within:

(A) 14 days after the eligibility determination for recipients determined eligible during the stay in the facility; or

(B) 90 days after the eligibility determination for recipients determined eligible after discharge from the facility;

(ii) cover the recipient's stay from admission through the date the certification is completed; and

(iii) be made by the facility team responsible for the recipient's plan of care as specified in 42 CFR, 441.155 and 441.156.

(d) All certificates of need must actually and personally be signed by each team member, except that signature stamps may be used if the team member actually and personally initials the document over the signature stamp.

(4) An authorization by the department or its utilization review agent under this rule is not a final or conclusive determination of medical necessity and does not prevent the department or its agents from evaluating or determining the medical necessity of services or items at any time.