Each Psychiatric Hospital must have in effect a written
Utilization Review Plan that provides for review of each member's need for
inpatient, partial hospitalization or outpatient services furnished by the
hospital and must meet the following requirements:
46.11-1
Utilization Review
Committee
A.
Utilization Review
Plan
The Plan must:
1. Provide for a committee to perform the
Utilization Review activities described in this manual;
2. Describe the organization, composition and
functions of the committee; and
3.
Specify the frequency of meetings of the committee.
B.
Organization and Composition of the
Utilization Review Committee
The Utilization Review Committee must be composed of two
or more physicians, at least one of whom is knowledgeable in the diagnosis and
treatment of mental diseases.
C.
Disqualification From Committee
Membership
The Utilization Review Committee must be constituted as a
committee of the hospital staff and may not include any individual who:
1. Is directly responsible for the care of
members whose care is being reviewed; or
2. Has a financial interest in any inpatient
psychiatric hospital.
46.11-2
Information Requirements
A.
Member Information
The Utilization Review Plan must provide that each
member's record include information needed to perform Utilization Review under
this manual. This information must include, at least, the following:
1. The member's name;
2. The name of the member's
physician;
3. Date of initiation of
service and, if application is made after initiation of service, dates of
application for and authorization of MaineCare benefits;
4. The plan of care described in section
46.10, above;
5. Initial and
subsequent continued service review dates described under Section
46.09;
6. Reasons and plan for
continued service, if the attending physician believes continued service is
necessary;
7. Other supporting
material that the committee believes appropriate for inclusion in the
record.
B.
Records
and Reports
The Utilization Review plan must describe:
1. The types of records that are kept by the
committee and
2. The type and
frequency of committee reports and arrangements for their distribution to
appropriate members.
C.
Confidentiality
The Utilization Review plan must provide that the
identities of members in all Utilization Review records and reports are kept
confidential.
46.11-3
Review of Need for Continued
Stay for Inpatient Services
A.
Continued Stay Review Required
The Utilization Review plan must provide for a review of
each member's continued stay in the inpatient psychiatric hospital to decide
whether it is needed, in accordance with the requirements of 46.11-3 (B)
through (H).
B.
Evaluation Criteria for Continued Stay
The Utilization Review plan must provide that:
1. The committee develops written medical
care criteria to assess the need for continued stay.
2. The committee develops more extensive
written criteria for cases that its experience shows are:
a. Associated with high costs;
b. Associated with the frequent furnishing of
excessive services; or
c. Attended
by physicians whose patterns of care are frequently found to be
questionable.
C.
Initial Continued Stay Review
Date
The Utilization Review Plan must provide that:
1. When a member is admitted to the inpatient
psychiatric hospital under admission review requirements of this manual the
committee assigns a specified date by which the need for his/her continued stay
will be reviewed;
2. If an
individual applies for MaineCare while in the hospital, the committee assigns
the initial continued stay review date within one (1) working day after the
hospital is notified of the application for MaineCare;
3. The committee bases its assignment of the
initial continued stay review date on:
a. The
methods and criteria required to be described under 46.11-3 (E)
below,
b. The member's condition,
and
c. The member's projected
discharge date.
4. The
committee uses any available appropriate regional medical care appraisal norms,
such as those developed by abstracting services or third party payors, to
assign the initial continued stay review date;
These norms are based on current and statistically valid
data on duration of stay for inpatient psychiatric hospitals for members whose
characteristics, such as age and diagnosis, are similar to those of the member
whose need for continued stay is being reviewed;
If the committee uses norms to assign the initial
continued stay review date, the number of days between the member's admission
and the initial continued stay review date is no greater than the number of
days reflected in the 50th percentile of the norms. However, the committee may
assign a later review date if it documents that the later date is more
appropriate;
5. The initial
continued stay review date is not in any case later than thirty (30) days after
admission of the member or thirty (30) days after notice to the inpatient
psychiatric hospital of his application for MaineCare; and
6. The committee insures that the initial
continued stay review date is recorded.
D.
Subsequent Continued Stay Review
Dates
The Utilization Review plan must provide that:
1. The committee assigns subsequent continued
stay review dates in accordance with 46.11-3(C), above, and 46.11-3(E),
below
2. The committee assigns a
subsequent continued stay review date within sixty (60) days each time it
decides under 46.11-3(F) below that the continued stay is needed, until one
hundred and twenty (120) days of service has been provided, and within thirty
(30) days each time it decides under 46.11-3(F) below that a continued stay is
needed after one hundred and twenty (120) days of service has been provided,
and
3. The committee insures that
each continued stay review date it assigns is recorded.
E.
Description of Methods and Criteria;
Continued Stay Review Dates; Length of Stay Modification
The Utilization Review plan must describe:
1. The methods and criteria, including norms
if used, that the committee uses to assign initial and subsequent review dates
under 46.11-3(C) and (D), above,
2.
The methods that the committee uses to modify an approved length of stay when
the member's condition or treatment schedule changes.
F.
Continued Stay Review Process
The Utilization Review plan must provide that:
1. Review of continued stay cases is
conducted by one of the following:
a. The
Utilization Review Committee;
b. A
subgroup of the Utilization Review Committee or
c. A designee of the Utilization Review
Committee;
2. The
committee, subgroup, or designee reviews a member's need for continued stay on
or before the expiration of each assigned continued stay review date;
3. For each continued stay of a member in the
inpatient psychiatric hospital, the committee, subgroup or designee reviews
and
4. evaluates the documentation
described under 46.11-2 against the criteria developed under 46.11-3(B) and
applies close professional scrutiny to cases described under
46.11-3(B)(2).
5. If the committee,
subgroup or designee finds that a member's continued stay in the inpatient
psychiatric hospital is needed, the committee assigns a new continued stay
review date in accordance with 46.11-3(D).
6. If the committee, subgroup, or designee
finds that a continued stay case does not meet the criteria, the committee or a
subgroup that includes at least one physician reviews the case to decide the
need for continued stay;
7. If the
committee or subgroups making the review under (5) of this Section finds that a
continued stay is not needed, it notifies the member's attending or staff
physician and gives him/her an opportunity to present his/her views before it
makes a final decision on the need for the continued stay;
8. If the attending or staff physician does
not present additional information to establish the need for the continued
stay, the decision of the committee or subgroup is final; and
9. If the attending or staff physician
presents additional information or clarification, at least two (2) physician
members of the committee, one of whom is knowledgeable in the treatment of
mental diseases, review the need for the continued stay. If they find that the
member no longer needs inpatient psychiatric hospital services their decision
is final.
G.
Notification of adverse decision
The Utilization Review plan must provide that written
notice of any adverse final decision, based on (1) through (8), above,
disaffirming the need for continued stay above is sent to:
1. The hospital administrator;
2. The attending or staff
physician;
3. The hospital
reimbursement officer;
4. The
member;
5. The next of kin, legal
guardian, or sponsor;
6. The third
party payor or MaineCare Office of Integrated Access and Support (OIAS);
and
7. The Department and its
Authorized Agent.
H.
Time limits for final decision and notification of adverse
decision
The Utilization Review plan must provide that the
committee makes a final decision concerning a member's need for continued stay
and gives notice of an adverse decision within two (2) working days after the
assigned continued stay review date. If the committee makes a final decision
denying a member's need for continued stay before the assigned review date,
notice under (G) above, is given within two (2) working days after the date of
the final decision.
46.11-4
Medical Care Evaluation for
Psychiatric Hospital Services
A.
Purpose and General Description
The purpose of medical care evaluations is to promote the
most effective and efficient use of available health hospitals and services
consistent with members' needs and professionally recognized standards of
health care.
Medical care evaluations:
1. Emphasize identification and analysis of
patterns of member care, and
2.
Suggest appropriate changes needed to maintain consistently effective and
efficient use of services.
B.
Utilization Review Plan Requirements
for Medical Care Evaluation
The Utilization Review plan must describe the methods
that the committee uses to select and conduct medical care evaluations.
The Utilization Review plan must provide that the
Utilization Review committee:
1.
Determines the methods to be used in selecting and conducting medical care
evaluations;
2. Documents the
results of each evaluation and how the results have been used to make changes
to improve the quality of care and promote more effective and efficient use of
hospitals and services;
3. Analyzes
the findings for each evaluation; and
4. Takes action as needed to correct or
investigate further any deficiencies or problems in the review process and to
recommend more effective and efficient hospital care procedures.
C.
Content of Medical Care
Evaluations
Each medical care evaluation must include the
following:
1. Identification and
analysis of medical or administrative factors related to member care;
2. Analysis of at least the following:
a. Admissions;
b. Duration of care;
c. Ancillary services furnished, including
drugs and biologicals; and
d.
Professional services performed.
3. If indicated, recommendations for change
beneficial to members, staff, the hospital, and the community.
D.
Data Sources For
Evaluations
Data that the committee uses to perform evaluations must
be obtained from one or more of the following sources:
1. Medical records or other appropriate
hospital data;
2. External
organizations that compile statistics, design profiles, and produce other
comparative data; or
3. Cooperative
endeavors with:
a. PSROs/PROs,
b. Fiscal agents,
c. Other service providers, and
d. Other appropriate agencies.
E.
Numbers Of
Evaluations Required To Be Performed
The psychiatric hospital must have at least one (1)
evaluation in progress at any time and complete one (1) evaluation each
calendar year.
