Current through Register Vol. 51, No. 19, September 20, 2024
A. Each
hospital shall appoint a utilization review agent to carry out the requirements
of the utilization review plan. When the agent is composed of hospital related
personnel the hospital's plan shall expressly designate the positions and the
organizational structure within the hospital that constitute the utilization
review agent for that institution.
B. Each utilization review plan shall set
forth the manner in which the agent:
(1)
Utilizes the services of doctors of medicine or osteopathy and other
practitioners capable of admitting patients, who are representative of
practicing physicians in the area in which the hospital is located.
(2) Has available the services of sufficient
numbers of physicians and dentists to assure the adequate review of medical
specialty and subspecialty cases.
(3) Utilizes the services of registered
nurses, medical records technicians, or similarly qualified persons supported
and supervised by physicians in carrying out its review activities.
(4) Uses only a doctor of medicine,
osteopathy, or dentistry to make a final determination that care rendered or to
be rendered was, is, or may be medically inappropriate.
(5) Makes direct comparisons with
professionally developed, objective criteria to determine the appropriateness
of admission and continued stay. The criteria should:
(a) Be nationally recognized and accepted,
unless a special exception is granted by the Secretary;
(b) Be capable of being utilized to define
the type and extent of services which are to be considered as within the range
of appropriate diagnosis and treatment for a given condition;
(c) Identify the level of care at which the
services can appropriately and economically be rendered; and
(d) Recognize that for many conditions more
than one mode or site of treatment or diagnosis may be medically
acceptable.
(6) Collects
information relevant to its function, maintains records, and reports to the
Department as required. The hospital's utilization review plan shall outline
the method by which patient confidentiality shall be maintained.
C. A member of the agent's staff,
or any person that the agent may delegate or employ, may not review or make a
determination of appropriateness for care that that person was directly
responsible for providing, or which was provided by or to a member of that
person's family.
