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

(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 client.

(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 PRTFs participating in the Medicaid program.

(3) Medicaid reimbursement is not available for PRTF services unless the provider submits to the department or its designee a complete and accurate certificate of need for services that complies with the requirements of 42 CFR, part 441, subpart D (2008) and these rules.

(a) For youth determined Medicaid eligible by the department at 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 youth's situation, including the youth's psychiatric condition. The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and a licensed mental health professional. No more than one member of the team of health care professionals may be professionally or financially associated with a PRTF program.

(b) For youth 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) admission has been prior authorized by the department or the department's designee.

(c) For youth who apply for and become Medicaid eligible after admission to the facility, the certificate of need must be made by the facility-based team responsible for the plan of care as specified in 42 CFR, 441.156:

(i) within 90 days of the eligibility determination and must cover any period before application for which claims are made; and

(ii) services are determined medically necessary by the department or the department's designee.

(d) All certificates of need must be actually and personally 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.