Updated Guidance for Continued Stay Reviews (CSR) in Section 97 Private Non-Medical Institution (PNMI) Appendix E
As previously communicated in the Department’s March 4, 2025, notice, PNMI Appendix E providers are required to submit clinical documentation supporting medical necessity every 90 days as part of each member’s CSR.
Required Documentation
Clinical documentation must be submitted through the Atrezzo system and must include the following member-specific information:
- Qualifying diagnosis
- The most recent Level of Care Utilization System (LOCUS) score from the past 12 months
- Current Individual Treatment Plan (ITP)
- Current Discharge Plan
In certain cases, additional documentation may be required to substantiate continued medical necessity. When applicable, providers must submit:
- Updated medical necessity form (listed in error in previous e-message under Required Documentation)
- Progress notes
- Incident reports
Updated Information for Timely Submission and Administrative Actions
If you submit the CSR, but do not include the required clinical documentation within the Atrezzo system submission window, the CSR is placed on an administrative hold for up to 14 days.
- If you submit the required clinical documentation within the 14-day hold period, the CSR is approved and effective the date the CSR is due.
- If you do not submit the required clinical documentation within the 14-day hold period, the CSR is administratively denied. Continued services are not authorized until receipt of all required documentation.
- If you submit a CSR with the required clinical documentation after the initial administrative denial, the effective date is based on the date the new CSR is received. It is not backdated to the effective date of the original CSR.
For questions, please contact Bruce Cosgrove, Provider Relations Specialist.